Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

Implementing VHA’s 

Mental Health Strategic Plan Initiatives 

for Suicide Prevention 

Report No. 06-03706-126 May 10, 2007

VA Office of Inspector General 

Washington, DC 20420 
To Report Suspected Wrongdoing in VA Programs and Operations 

Call the OIG Hotline – (800) 488-8244 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

Contents 

Executive Summary ..............................................................................................i

Purpose .................................................................................................................1 

Background ..........................................................................................................2 

Epidemiology................................................................................................................... 2

Surgeon General’s National Strategy for Suicide Prevention: A Public Health 

Approach.......................................................................................................................... 8 

Institute of Medicine’s Reducing Suicide: A National Imperative................................ 12 

President’s New Freedom Commission on Mental Health Report Achieving the 

Promise: Transforming Mental Health Care in America.............................................. 12

Under Secretary for Health’s A Comprehensive VHA Strategic Plan for Mental 

Health Services.............................................................................................................. 14

Scope and Methodology....................................................................................17

Survey of VHA Facilities .............................................................................................. 17

Field Interviews ............................................................................................................. 18

Benchmark Considerations............................................................................................ 19

Findings ..............................................................................................................21

Crisis Availability and Outreach ................................................................................... 22

Screening and Referral................................................................................................... 28

Tracking and Assessment of Veterans at Risk .............................................................. 33

Emerging Best Practice Interventions and Research..................................................... 37

Development of an Electronic Suicide Prevention Database ........................................ 44 

Education ....................................................................................................................... 45

Conclusions........................................................................................................51

Recommendations .............................................................................................54

Appendixes

A. Survey Questions ...................................................................................................... 56 

B. Acting Under Secretary for Health Comments......................................................... 58

C. OIG Contact and Staff Acknowledgments................................................................ 66

D. Report Distribution ................................................................................................... 67 

E. Citations..................................................................................................................... 68

VA Office of Inspector General 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

Executive Summary 

Introduction 

The purpose of this review was to assess the implementation of action items that pertain 

to suicide prevention within the Veterans Health Administration’s (VHA’s) Mental 

Health Strategic Plan (MHSP). 

There are approximately 25 million veterans in the United States and 5 million veterans 

who receive care within VHA. Based on Centers for Disease Control and Prevention 

data indicating suicide rates in men between the ages of 20 and 65 approximating 20 per 

100,000 persons per year, VHA mental health officials estimate 1,000 suicides per year 

among veterans receiving care within VHA and as many as 5,000 per year among all 

living veterans. To better understand the characteristics of suicide in veterans, we 

reviewed studies on suicide in the general population. These studies can be summarized 

as follows. 

• In the United States there are approximately 30,000 suicide deaths and 1.4 million 

suicide attempts per year. This generates many hospital admissions as well as 

visits to hospital emergency rooms. 

• On average there are four male suicide deaths for each female death by suicide; 

however, there are three female suicide attempts for each male suicide attempt. 

• Firearms were the most frequent means of completed suicide death in each adult 

age range, accounting for 51 percent of overall completed suicides. 

• Numbers are somewhat different with regard to attempted suicide. Whereas 

firearms, hanging, or jumping are the more common methods in attempted male 

suicides, females are more likely to attempt by taking an overdose of medication 

or ingesting a poison. 

• Among the population of those who commit suicide, there is a greater incidence of 

impulsivity in other settings, which is a tendency also associated with closed head 

injury and patients at risk for alcohol and substance abuse. 

• The best single indicator that a patient is at increased risk of suicide may be a 

history of a prior suicide attempt. Up to 40 percent of depressed patients who 

commit suicide have made a previous attempt. The risk of a patient making a 

second attempt is highest within the 3 months following the first attempt. Some 

studies indicate that up to two-thirds of patients who commit suicide have seen a 

physician in the month before their death. Among the older adult male subpopulation, the majority tend not to seek mental health treatment. However, 

studies indicate that many who commit suicide have seen their primary care 

provider within the month of their death. 

This report also briefly summarizes relevant findings and types of recommendations from 

related reports addressing prevention of suicide. These reports have been produced 

VA Office of Inspector General i 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

during the last decade by the Surgeon General of the United States, the Institute of 

Medicine, and the President’s New Freedom Commission on Mental Health. VA’s 

Under Secretary for Health charged a work group to review the 2002 report of the 

President’s New Freedom Commission on Mental Health and to develop an action 

agenda tailored to the mental health needs of veterans enrolled for care in VA. In 

December 2003, VHA published an Action Agenda which, along with other reports, led 

to the development of VHA’s MHSP, which was finalized in November 2004. 

The purpose of the 2004 MHSP was to present a new approach to mental health care, an 

approach which was focused on recovery rather than pathology, and to integrate mental 

health care into overall health care for veteran patients. This 5-year action plan with 

more than 200 initiatives includes timetables and responsible offices identified for each 

action item. Among these action items were a number specifically aimed at the 

prevention of suicide. Other factors that influenced the MHSP Work Group included the 

return of veterans from Iraq and Afghanistan, the challenge to deliver quality mental 

health services to a growing number of women veterans, and the changing and future 

mental health service needs of aging Vietnam Era veterans. 

In response to a request from a member of the U.S. House of Representatives, Committee 

on Veterans’ Affairs, the Office of Inspector General undertook an assessment of VHA’s 

progress in implementing the MHSP initiatives for suicide prevention. Specifically, 

those initiatives that pertain to suicide prevention include the following. 

• Develop methods for tracking veterans with risk factors for suicide and systems 

for appropriate referral of such patients to specialty mental health care. 

• Develop a plan to educate all staff who interact with veterans, including clerks and 

telephone operators, about responding to crisis situations involving at-risk 

veterans. This would include suicide protocols for intake, telephone operators, 

and other first contact personnel. 

• Develop mandatory education programs for VA health care providers about 

suicide risks and ways to address these risks. Incorporate best practices for suicide 

prevention. 

• Promote evidence based strategies for suicide assessment and prevention including 

emphasis on special emphasis groups. 

• Develop and test an electronic suicide prevention database. 

• Develop a national systematic program for suicide prevention. 

• Endorsement and implementation of the National Strategy for Suicide Prevention

(2001) and the Institute of Medicine’s report, Reducing Suicide: A National 

Imperative (2002). 

• Develop a plan for 24-hour mental health care availability through VHA. 

• Medical centers establish contacts through the Chaplain Service with faith-based 

organizations and community resources to assist with culturally competent suicide 

prevention and other mental health issues at local and national levels. 

VA Office of Inspector General ii 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

• Support for a new Mental Illness, Research, Education Clinical Center (MIRECC) 

with focus on suicide prevention, in collaboration with other MIRECC’s working 

in this area. 

Methodology

In order to assess VHA’s progress in implementing initiatives for suicide prevention, we 

surveyed all VA medical centers between December 2006 and February 2007. Surveys 

were sent to facility Chiefs of Staff, to be done in collaboration with clinicians from 

mental health, primary care, and quality management. Follow-up questions within the 

survey captured descriptions of applicable programs or implemented strategies. It was 

possible for facilities to describe local innovations. One-hundred-ten facilities from 17 

Veterans Integrated Service Networks (VISNs) responded; 4 VISNs had no facility 

responses. During the survey time frame, we conducted extensive personal interviews of 

VHA leadership, researchers, and subject matter experts in the field to assess the extent 

of progress, learn about innovations, and validate survey responses. We assessed 

implementation of MHSP initiatives along a spectrum of five stages: (1) we could find 

no evidence of plans for implementation, (2) we found evidence of planning but not 

piloting or local implementation, (3) we found evidence of ongoing or completed pilot or 

demonstration projects, (4) we found implementation throughout an entire VISN or in 

multiple facilities in multiple VISNs, and (5) we found system-wide implementation. 

(The extent of implementation for each suicide prevention initiative unique to the MHSP 

can be seen in the chart on page 54.) 

Conclusions 

MHSP initiatives pertaining to 24-hour crisis availability, outreach, referral, and 

development of methods for tracking veterans at risk have been implemented throughout 

an entire VISN or in multiple facilities in multiple VISNs but not yet system-wide. 

Initiatives focused on the development of methods for screening, assessment of veterans 

at risk, emerging best practice treatment interventions, and an electronic suicide 

prevention database have been piloted or are in the process of being piloted at select 

facilities. Development of mandatory education programs for VA health care providers 

about suicide risks and ways to address these risks, and a plan to educate first contact 

personnel about responding to crisis situations involving at-risk veterans have been 

piloted or are in the process of being piloted at select facilities. The VISN 19 MIRECC 

has been established with a focus on suicide prevention and has been providing 

leadership in collaboration with other MIRECCs working in this area. 

Since 2004, progress has been made toward the implementation of the MHSP initiatives 

for suicide prevention. The progress is ongoing, with greater integration and at an 

accelerated pace. However, more work remains to ensure a coordinated effort in 

achieving system-wide implementation. Central to this effort is the ongoing need for 

VA Office of Inspector General iii 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

greater integration of local, network, and national level projects and innovations; a 

readiness to make difficult choices among best available options; and the impetus to 

translate this readiness into widespread and sustained implementation. 

In the near term, system-wide implementation of a set of promising and/or emerging best 

practices, coupled with their ongoing evaluation and modification, would facilitate 

provision of a single standard of preventative care for all veterans seen at VHA facilities. 

A national system-wide suicide prevention plan is intended to provide proactive 

strategies for identifying, screening, assessing, referring, tracking, and treating veterans at 

risk. At present, MHSP initiatives for suicide prevention are partially implemented. It is 

therefore incumbent upon VHA to continue moving forward toward full deployment of 

suicide prevention strategies for our Nation’s veterans. 

Recommendations 

We concluded that significant progress had been made, but more work remains to be 

done to achieve system-wide implementation. We recommended that: 

• VHA facilities should make arrangements for 24-hour crisis and mental health care 

availability, either in person or by a VA facility or a non-VA crisis/suicide hotline 

staffed by trained personnel. In addition, an on-call mental health specialist should 

be available to crisis staff either in person or by phone. 

• All non-clinical staff who interact with veterans should receive mandatory training 

about responding to crisis situations involving at-risk veterans; this should include 

suicide protocols for first contact personnel. 

• All health care providers should receive mandatory education about suicide risks 

and ways to address these risks. 

• A requirement of sustained sobriety should not be a barrier to treatment in 

specialized inpatient post-traumatic stress disorder (PTSD) programs for returning 

combat veterans. 

• VHA should facilitate bi-directional information exchange between VA and 

Department of Defense, both for patients with mental illness entering VHA health 

care and/or leaving VHA for re-deployment to active duty status. 

• VHA should establish a centralized mechanism to select emerging best practices for 

screening, assessment, referral, and treatment and to facilitate system-wide 

implementation, in order to ensure a single VHA standard of suicide prevention 

excellence. 

Under Secretary for Health Comments 

The Acting Under Secretary for Health reviewed the draft report and concurred with the 

recommendations to ensure a more coordinated effort of implementing proactive suicide 

prevention strategies throughout VHA. VHA’s goal is to ensure continual awareness and 

prevention of suicide among veterans. 

VA Office of Inspector General iv 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

VHA has recently designated Suicide Prevention Coordinators in each medical center. 

Beginning on March 1, 2007, VHA established an annual Veteran Suicide Prevention 

Awareness Day. This will enhance suicide prevention education for clinicians and nonclinical staff, throughout the VA health care system. Each Vet Center, VISN, and 

medical center will hold Veterans Suicide Prevention Day annually to conduct suicide 

prevention programs and activities, to include educational presentations that are extended 

during the year through a number of VHA Employee Education System programs. 

VHA is also in the process of developing additional awareness and training protocols at 

the local level that involve training of front-line patient contact personnel on the concepts 

of suicide recognition, early interventions, and the steps necessary in responding to crisis 

and obtaining assistance for veterans at risk of suicide. Awareness training on suicide 

prevention for clinical personnel is also under development. Although these efforts are 

already outlined with target dates in the MHSP, they have expedited these initiatives to 

limit any remaining gaps in service delivery involving suicide prevention. 

Assistant Inspector General for Healthcare Inspections Comments 

The Acting Under Secretary for Health agreed with the findings and recommendations 

and provided acceptable improvement plans. (See Appendix B, pages 58–65 for the full 

text of the comments.) We will follow up on the planned actions until they are 

completed. 

 (original signed by:) 

JOHN D. DAIGH, JR., M.D. 

Assistant Inspector General for 

Healthcare Inspections 

VA Office of Inspector General v 
DEPARTMENT OF VETERANS AFFAIRS

Office of Inspector General 

Washington, DC 20420 

TO: Acting Under Secretary for Health (10) 

SUBJECT: Implementing VHA’s Mental Health Strategic Plan Initiatives for 

Suicide Prevention 

Purpose 

In response to a request from a member of the U.S. House of Representatives, Committee 

on Veterans’ Affairs, the Office of Inspector General (OIG) undertook an assessment of 

Veterans Health Administration’s (VHA’s) progress in implementing initiatives for 

suicide prevention from A Comprehensive VHA Strategic Plan for Mental Health 

Services. Centers for Disease Control and Prevention (CDC) data indicate that in 2004 

there were 32,439 known completed suicides in the United States, which accounted for 

1.4 percent of overall deaths. Suicide ranked as the 11th leading cause of death in 2004, 

with an overall rate of 11.1 suicides per 100,000 U.S. population.1

 Suicide was the 2nd

leading cause of death in people ages 25–34, the 3rd leading cause of death in ages 15–24, 

and the 4th leading cause of death in ages 35–44.2

 It is estimated that each suicide 

intimately affects at least six other people. Based on the 754,570 reported suicides from 

1980–2004, approximately 4.5 million, or 1 in every 65, Americans in 2004 was a 

survivor of suicide (that is, family members and friends of a loved one who died by 

suicide).3

 

There are approximately 25 million veterans in the United States, and 5 million veterans 

who receive care within VHA. Based on CDC data indicating suicide rates in men 

between the ages of 20 and 65 approximating 20 per 100,000 persons per year and not 

controlling for VHA population specific epidemiologic factors, VHA mental health 

officials estimate 1,000 suicides per year among veterans receiving care within VHA and 

as many as 5,000 per year among all living veterans.4

 

In this report we review what is known about the characteristics, nature, and rates of 

suicide. We also summarize related reports from the Surgeon General of the United 

States, the Institute of Medicine, and the President’s New Freedom Commission on 

Mental Health, as well as A Comprehensive VHA Strategic Plan for Mental Health 

Services, known generally as VHA’s Mental Health Strategic Plan (MHSP). 

VA Office of Inspector General 1 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

The 2004 MHSP is a plan for the transformation of VA mental health care. It is an action 

plan that presents goals and objectives that convey a set of proposed strategies to support 

the mental health needs of the enrolled veteran population. The action plan includes over 

200 proposed initiatives or action items. The initiatives are grouped in alignment with 

mental health strategies aimed at ultimately achieving the goals and recommendations set 

forth in the President’s New Freedom Commission on Mental Health report of 2003.5

 

The purpose of this OIG Office of Healthcare Inspections (OHI) review is to assess the 

nature, progress, and extent of VHA’s implementation of those action items within the 

MHSP that pertain to suicide prevention. 

We conducted the inspection in accordance with the Quality Standards for Inspections

published by the President’s Council on Integrity and Efficiency. 

Background 

A. Epidemiology 

Suicide is the behavior of actively seeking self-destruction. The degree of life 

threatening intensity varies among those who display suicidal behavior. Essentially all of 

these individuals are suffering from one or another psychiatric condition that predisposes 

them to the behavior. Recent life events that provoke feelings of loss and hopelessness as 

well as sociocultural and demographic factors add to a person’s suicidal risk. 

In any particular suicide, individual and collective proclivities tend to combine. 

Consequently, the attempt to make sense of the multiple potential contributions from 

identifiable psychiatric disorder(s), co-morbid medical illness, specific personal events, 

and sociocultural factors has been the work of and an ongoing challenge to mental health 

professionals, sociologists, and epidemiologists for several decades. This effort has 

increased knowledge about suicidal patients and provided information for utilization in 

their treatment. However, there has been little if any reduction in overall suicide rates 

through the years, a discouraging fact indicating there is more to learn.6

 

In the United States there are nearly 30,000 suicide deaths and 1.4 million suicide 

attempts per year, resulting in 1.3 million years of life lost.7

 In 1999, more than 152,000 

hospital admissions and more than 700,000 visits to the hospital emergency rooms were 

for self-harming behaviors.8

 Overall, suicide was the 11th leading cause of death in 2004 

but the 2nd leading cause of death in the 25-34 age group, as shown in the following data 

from the Centers for Disease Control and Prevention (CDC).9

VA Office of Inspector General 2 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

Leading Causes of Death in the United States for All Races, Both Sexes in 2004 

Age Groups 

ank <1 1-4 5-9 10-14 15-24 25-34 35-44 45-54 55-64 65+ All Ages 

1 

Congenital 

Anomalies 

5,622 

Unintentional 

Injury 

1,641 

Unintentional 

Injury 

1,126 

Unintentional

Injury 

1,540 

Unintentional

Injury 

15,449 

Unintentional

Injury 

13,032 

Unintentional

Injury 

16,471 

Malignant

Neoplasms 

49,520 

Malignant 

Neoplasms 

96,956 

Heart 

Disease 

533,302 

Heart 

Disease 

652,486 

2 

Short 

Gestation 

4,642 

Congenital 

Anomalies 

569 

Malignant 

Neoplasms 

526 

Malignant

Neoplasms 

493 

Homicide 

5,085 

Suicide 

5,074 

Malignant

Neoplasms 

14,723 

Heart 

Disease 

37,556 

Heart 

Disease 

63,613 

Malignant

Neoplasms 

385,847 

Malignant

Neoplasms 

553,888 

3 SIDS 

2,246 

Malignant 

Neoplasms 

399 

Congenital 

Anomalies 

205 

Suicide 

283 

Suicide 

4,316 

Homicide 

4,495 

Heart 

Disease 

12,925 

Unintentional

Injury 

16,942 

Chronic Low. 

Respiratory

Disease 

11,754 

Cerebrovascular 

130,538 

Cerebrovascular 

150,074 

4 

Maternal 

Pregnancy

Comp. 

1,715 

Homicide 

377 

Homicide 

122 

Homicide 

207 

Malignant

Neoplasms 

1,709 

Malignant

Neoplasms 

3,633 

Suicide 

6,638 

Liver 

Disease 

7,496 

Diabetes

Mellitus 

10,780 

Chronic Low.

Respiratory

Disease 

105,197 

Chronic Low.

Respiratory

Disease 

121,987 

5 

Unintentional 

Injury 

1,052 

Heart 

Disease 

187 

Heart 

Disease 

83 

Congenital

Anomalies 

184 

Heart 

Disease 

1,038 

Heart 

Disease 

3,163 

HIV 

4,826 

Suicide 

6,906 

Cerebrovascular 

9,966 

Alzheimer's

Disease 

65,313 

Unintentional

Injury 

112,012 

6 

Placenta 

Cord 

Membranes 

1,042 

Influenza 

& Pneumonia 

119 

Chronic Low. 

Respiratory

Disease 

46 

Heart 

Disease 

162 

Congenital

Anomalies 

483 

HIV 

1,468 

Homicide 

2,984 

Cerebrovascular 

6,181 

Unintentional 

Injury 

9,651 

Diabetes

Mellitus

53,956 

Diabetes

Mellitus

73,138 

Source: CDC, National Center for Injury Prevention and Control, http://webappa.cdc.gov/sasweb/ncipc/leadcaus10.html. 

Note: On the CDC website, you can click on any of the colored boxes for detailed causes and ICDA codes.

R

The overall U.S. suicide rate in 2004 was 11.1 persons per 100,000; but rates vary 

dramatically according to age and gender as shown in the following chart. Suicide rates 

are highest in white males (19.6 per 100,000) followed by Native Americans (12.9 per 

100,000) and black males (9.0 per 100,000). The older end of the age range comprised 

12.4 percent of the population in 2004 but represented 16 percent of the suicides. The 

rates among those ages 75–84 were 16.3 per 100,000. The younger age groups (15–34) 

comprised 14.2 percent of the 2004 population but 13.3 percent of the suicides. 

However, the greater absolute number of suicides occurred in the 35–54 age range.10 In 

addition, the pattern of suicide rates by age varies for men and women.11

 

A ICD – the International Classification of Diseases is published by the World Health Organization and is used 

world-wide for morbidity and mortality statistics, reimbursement systems, and automated decision support in 

medicine. 

VA Office of Inspector General 3 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

On average there are 4 male suicide deaths for each female death by suicide, but there are 

3 female suicide attempts for each male suicide attempt—ratios which have been 

relatively stable over time. Of the 32,439 overall suicide death figure cited in the 2004 

CDC National Center for Health Statistics, 25,566 suicides were among males and 6,873 

were among females.12 Firearms were the most frequent means of completed suicide 

death in each adult age range, accounting for 51 percent of overall completed suicides. 

Among the 15–24 age group, firearms were involved in 49 percent of suicides (see the 

following chart on Methods of Suicide Death).13 In addition, firearms are the leading 

means of completed suicide among women as well as men. However, whereas firearms, 

hanging, or jumping are more common methods in attempted male suicides, females are 

more likely to attempt by taking an overdose of medication or ingesting a poison. 

VA Office of Inspector General 4 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

Method of Suicide Death in 2004 for Ages 15–24, All Races, Both Sexes 

Data Source: National Center for Health Statistics (NCHS), National Vital Statistics System 

NEC = Not otherwise classifiable 

There are regional and state-by-state variations in suicide rates, with higher rates reported 

in the Mountain and East South Central sub-divisions and lower rates reported in the East 

North Central and Middle Atlantic sub-divisions. Suicide rates are highest in the Rocky 

Mountain States. Some data indicate higher rates in rural areas.14

Suicide 

 1989-1998

Legend # of Counties 

At or above the 90th 

NATIONAL percentile (308) 

At or above the 75th but 

less than the 90th 

NATIONAL percentile 

(460) 

Less than the 75th 

NATIONAL percentile (2304) 

Source: National Center for Health Statistics 

Data from the 1990–92 National Co-Morbidity Survey, a face to face survey of a sample 

of participants ages 18–54, who were queried about suicidal ideation in the prior 12 

months, found that 2.8 percent of the replication group reported having experienced 

suicidal ideation, 0.7 percent reported having had a suicide plan, 0.3 percent reported 

having made a suicide gesture, and 0.4 percent reported having made a suicide attempt. 

VA Office of Inspector General 5 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

Thirty-nine-point-three percent of attempters reported having made a serious life 

threatening attempt, 13.3 percent a serious but not foolproof method, and 47.3 percent 

reported making a “cry for help,” but not wanting to die. The cumulative probability for 

transition from ideation to plan was 34 percent, from plan to attempt was 72 percent, and 

from ideation to unplanned attempt was 26 percent. The survey found a prevalence of 

major depression of 34–42 percent among the four categories of suicidality and a 

prevalence of anxiety of 63–78 percent among participants in the four categories. The 

study was replicated in 2001–2003 with similar results.15

Psychological autopsy studies from the U.S., Finland, Sweden, and the United Kingdom 

have found that as many as 90 percent of people who kill themselves have a diagnosable 

mental or substance abuse disorder. Follow-up studies of adults with mental or substance 

abuse disorders also reveal a high risk of suicide associated with these disorders. Studies 

have indicated that the lifetime risk for suicide is 6 times higher for persons with 

diagnosable depression than for those without depression. Among persons with 

schizophrenia, the risk for suicide is between 4–6 percent over the life-long course of the 

illness but with higher risk earlier in the course of the illness. It is estimated that 

approximately 7 percent of those with alcohol dependence will die by suicide. Adult 

patients who report high rates of suicide attempts also include women with borderline 

personality disorder; men and women with depression who also abuse drugs or alcohol; 

and men and women with bipolar depression. In addition, co-morbid alcohol and 

substance use further complicates suicide risk in those with co-morbid psychiatric 

diagnosis, especially in the younger age ranges.16 

Investigators have noted that suicide involves aggression and is often carried out 

impulsively. Among the population of those who commit suicide, there is a greater 

incidence of impulsivity in other settings, which is a tendency also associated with closed 

head injury and patients at risk for alcohol and substance abuse. In addition, research 

studies have demonstrated a lower level of the serotonin metabolite 5-HIAA in the 

cerebrospinal fluid of a sample of patients who had made or completed serious suicide 

attempts and also in studies of groups of other individuals with histories of impulsive, 

externally directed aggression. Further highlighting the potential contribution of 

impulsive or aggressive personality factors to some cases of suicide is study data that 

found that 25 percent of 153 survivors of near lethal suicide attempts acted within 5 

minutes of the impulse and 71 percent acted within 1 hour.17 Additionally, the presence 

of alcohol use or a history of traumatic brain injury may cause or exacerbate impulsivity 

and disinhibited behavior. 

Perhaps the best indicator that a patient is at increased risk may be a history of a prior 

suicide attempt. For example, some studies have shown that up to 40 percent of 

depressed patients who commit suicide have made a previous attempt. The risk of a 

patient making a second attempt is highest within the 3 months following the first 

attempt. Some studies indicate that up to two-thirds of patients who commit suicide have 

VA Office of Inspector General 6 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

seen a physician in the month before their death. Among the older adult male subpopulation, the majority tend not to seek mental health treatment. However, studies 

indicate that many who commit suicide have seen their primary care provider within the 

month of their death.18

In 2002, the VA National Center for Patient Safety (NCPS) looked at a convenience 

sample of 400 suicide and parasuicideB root cause analysis (RCA)C reports from VA 

medical centers, relying heavily upon narrative detail in each RCA. The review, which 

included 10 inpatient suicides, 293 outpatient suicides, 47 inpatient parasuicides, and 45 

outpatient parasuicides, indicated that 34 percent of patients had made a previous attempt. 

Of these patients, 42 percent had a history of alcohol dependence, 19 percent a history of 

street drug dependence, and 16 percent a history of prescription medicine dependence. 

For the total 400 patients, the last contact was with outpatient mental health for 

42 percent, inpatient mental health for 25 percent, and outpatient primary care for 

25 percent. More specifically, for outpatient suicides 78 percent had contact with a 

provider (either mental health or primary care provider) within the month prior to 

suicide.19 

In a Danish study that made use of data registries containing information on the Danish 

population from 16–78 years of age in the period from 1980–1994, researchers matched 

811 suicides that occurred with 79,871 control subjects and performed multiple statistical 

analyses to identify key variables associated with suicide. In this population, the 

strongest risk factor by far was a history of admission to a psychiatric hospital; regardless 

of diagnosis, the greatest period of risk was during hospital admission and in the first 

week following discharge.20 

Additionally, suicide of a care recipient while in a staffed, round-the-clock care setting 

has been the most frequently reported type of sentinel event since the inception of the 

Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Sentinel Event 

Policy in 1996. As a result, the JCAHO’s 2007 National Patient Safety Goals require that 

organizations identify patients at risk for suicide. The requirement applies only to 

patients admitted within psychiatric hospitals and patients being treated for emotional or 

behavioral disorders in the general hospital. The requirement (15A) includes the 

expectations that risk assessment includes identification of specific factors that may 

increase or decrease risk for suicide; the patient’s immediate safety needs and most 

appropriate setting for treatment are addressed; and the organization provides information 

such as a crisis hotline to individuals and their family members for crisis situations.21 

 

B

 Parasuicide refers to a suicidal gesture or a suicide attempt which does not result in death (a completed suicide). 

NCPS defines it as “Any suicidal behavior, with or without physical injury, short of death including the full range of 

known or reported attempts, gestures, or threats.” 

C

 The goal of a root cause analysis or RCA is to find out what happened, why it happened, and to determine what 

can be done to prevent it from happening again. RCAs are used to focus on improving and redesigning systems and 

processes, rather than to focus on individual performance. 

VA Office of Inspector General 7 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

Environmental and sociocultural risk factors also include job or financial loss, relational 

or relationship loss, easy access to lethal means, lack of social support and sense of 

isolation, stigma associated with help-seeking behavior, barriers to accessing health care, 

certain cultural or religious beliefs, and exposure to, including through the media, and 

influence of others who have died by suicide.22

VA is one of the largest integrated health systems in the world, and the largest provider 

of mental health care. Although the demography is changing as the number of women 

veterans increases, veterans in general are fairly representative of the overall U.S. male 

population. However, only a small proportion of veterans seek care from VA. As a 

whole, those veterans who do seek care through VA are poorer and sicker than the 

general population of veterans. In particular, they are more likely to be disabled and to 

have a psychiatric disorder.23

Using data (with methodological limitations) from studies that predate Operation 

Enduring Freedom/Operation Iraqi Freedom (OEF/OIF), some VHA researchers had 

previously estimated suicide rates among VHA facility users to be as high as 83 per 

100,000 in the less-than 65 age group and 45 per 100,000 in the older-than age 65 age 

group; this reflects a higher at-risk population (or higher relative proportion of at-risk 

patients) than the overall general population.24 At-risk patients seen in VHA and nonVHA settings include patients with schizophrenia and other psychotic illness, recurrent 

major depression, bipolar spectrum disorder, panic disorder and post-traumatic stress 

disorder (PTSD), substance abuse disorders, dual diagnosis (serious mental illness and 

substance abuse) and aging adults. Sub-populations particular to the VA who are or may 

be at increased risk include patients with combat zone related PTSD, traumatic brain 

injury (TBI), traumatic amputation and/or disfigurement, spinal cord injury, those who 

have experienced military sexual trauma (MST), and combinations of the above.25 

The following introductory sections will review the development of the VHA Mental 

Health Strategic Plan and will briefly highlight the public health approach to suicide 

prevention presented in the Surgeon General’s National Strategy for Suicide Prevention

(NSSP) report; the Institute of Medicine (IOM) report, Reducing Suicide: A National 

Imperative; and the report of the President’s New Freedom Commission on Mental 

Health, Achieving the Promise: Transforming Mental Health Care in America. 

B. Surgeon General’s National Strategy for Suicide Prevention: A Public Health 

Approach 

Recognizing that mental and substance abuse disorders confer the greatest risk for 

suicidal behavior, the Surgeon General’s Call to Action (1999) suggested a blueprint for 

addressing suicide and injuries from suicidal behavior by addressing the problems of 

undetected and under treated mental health and substance abuse disorders in conjunction 

with other public health approaches. The Call to Action proposed a conceptual 

foundation designated “AIM.” The elements of “AIM” were Awareness: Broaden the 

VA Office of Inspector General 8 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

public’s awareness of suicide and its risk factors; Intervention: Enhance services and 

programs, both population-based and clinical care; and Methodology: Advance the 

science of suicide prevention. The AIM framework included 15 recommendations 

derived from consensus-based and evidence-based findings intended to serve as a 

foundation for a more comprehensive National Strategy for Suicide Prevention.

26 

The NSSP (2001) is intended as a highly ambitious, comprehensive, and integrated 

approach to reducing the loss and suffering from suicide and suicidal behaviors across the 

life course. The NSSP represents the first attempt in the United States to prevent suicide 

through a coordinated approach by both the public and private sectors. The editors noted 

that “suicide is an outcome of complex interactions among neurobiological, genetic, 

psychological, social, cultural, and environmental risk and protective factors.... 

Development of a national strategy can bring together multiple disciplines and 

perspectives to create an integrated system of interventions across multiple levels, such as 

the family, the individual, schools, the community, and the health care system.... An 

evidence-based national strategy can maximize success when recommendations are 

implemented locally. Sound evaluation of community programs, in turn, builds the 

evidence base.”27 

The NSSP articulates a set of 11 goals and 68 objectives intended as a roadmap for action 

to help guide an informed selection of activities for suicide prevention across the 

spectrum of the nation. The editors noted that the next step would be to develop a 

detailed plan that includes specific activities corresponding to each objective. 

The NSSP roadmap is based on a public health approach adapted for suicide. In contrast 

to the clinical approach of exploring the clinical history, health, behavior, and life events 

of a single individual, the public health approach focuses on identifying patterns of 

suicide and suicidal behavior throughout a group or population. The five basic steps of 

the public health approach are depicted in the following diagram: 

VA Office of Inspector General 9 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

 From the National Strategy for Suicide Prevention, p. 29. 

The steps depicted may occur in sequence but sometimes overlap. For example, 

information gained from evaluations may lead to new and promising interventions. 

Surveillance helps define a problem for a community. Collecting data on rates of suicide 

and suicidal behavior typically comprises surveillance. Surveillance data includes 

information on how suicide rates vary by time, geography, age, or special populations. In 

addition, surveillance may include collection of information on characteristics of 

individuals who suicide, circumstances surrounding suicide events, the presence and 

absence of possible precipitants, and the adequacy or accessibility of supportive factors 

and health services.28 

Risk factors are those elements that may be thought of as leading to or being associated 

with suicide and were discussed in the preceding section. Protective factors tend to 

enhance resilience, and may serve to counterbalance risk factors and reduce the 

likelihood of suicide. Protective factors include effective clinical care for mental, 

physical, and substance use disorders; easy access to a variety of clinical interventions 

and support for help seeking; restricted access to highly lethal means; strong connections 

to family and community support; support through ongoing medical and mental health 

care relationships; skills in problem solving and conflict resolution; and cultural and 

religious beliefs that discourage suicide and support self-preservation. Understanding 

interactive relationships between multiple risk factors, between risk factors and protective 

factors, and how these interactions can be modified are challenges to suicide 

prevention.29 

Suicide prevention interventions may be developed to attempt to influence some 

component or combination of psychological, physical, environmental or cultural 

VA Office of Inspector General 10 
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conditions. Alternatively, suicide prevention efforts may be divided into a universal 

approach intended for everyone in a population regardless of risk (e.g., reducing stigma 

in the community), a selective approach for subgroups at increased risk, and an indicated 

approach designed for patients such as previous suicide attempters, whose examination 

reveals factors that put them at very high risk.30 The universal approach is consistent 

with the notion known as Rose’s TheoremD that “a large number of people at small risk 

may give rise to more cases of disease than a small number who are at high risk.”31 

Rigorous testing to evaluate efficacy and effectiveness of interventions is important to 

ensure that interventions are safe and feasible prior to their larger scale implementation. 

Testing usually includes small scale pilot studies or demonstration projects. Efficacy 

studies ask the question, “under ideal conditions, can an intervention work?” When 

proposed interventions are found to be safe and feasible, further testing with larger 

groups can lead to refinements or adaptation for group differences based on factors such 

as age, gender, or region. Effectiveness studies undertaken in actual clinical settings ask 

the question, “in the real world, does it prevent suicide?” The editors of the NSSP note 

that it is frequently difficult to conduct efficacy studies; and they add: “in actuality, 

definitive pilot studies are frequently missing for many types of social and mental health 

interventions, including those designed to prevent suicide. By default, program planners 

may incorporate ‘promising’ interventions into community suicide prevention plans 

before the evidence base is fully developed. This makes careful evaluation of local 

outcomes especially important.” 

Comprehensive suicide prevention programs—those employing a portfolio of 

intervention elements, and particularly those that incorporate a range of services and 

providers—are thought to have a greater likelihood of reducing suicide rates. Selecting 

which interventions to implement includes consideration of the needs and characteristics 

of the target population, ways to integrate interventions into existing programs, efforts to 

strengthen collaboration, and an analysis weighing the resource requirements versus the 

potential effectiveness of individual interventions.32 

Evaluation is a tool used to ensure that programs, such as those designed to prevent 

suicide, accomplish what they intend. Evaluation may be concerned with the outcomes 

of interventions or the functioning of intervention programs. Evaluation can help 

determine for whom a particular strategy is best fitted and how it should be modified to 

improve efficacy. An outcome evaluation uses quantifiable data to determine whether or 

not a program has had the desired effects. While evaluation is often thought of in terms 

of overall or ultimate outcome, sometimes a more general question or proxy measure is 

examined. For example, it may look at the ability of an outreach program to actually 

reach people at risk. A process evaluation focuses on implementation. By documenting 

a program’s development and operation, a process evaluation can provide understanding 

of the performance of a program, enhance a project’s ability to stay on course, ensure 

 

D Rose, G.: The Strategy of Preventive Medicine. Oxford, England, Oxford University Press, 1992. 

VA Office of Inspector General 11 
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accountability by comparing actual performance with expectations, and provide an 

opportunity to make mid-course modification and to identify problems or gaps that need 

attention.33 Endorsement and implementation of the goals from NSSP is incorporated 

into the VHA Mental Health Strategic Plan. 

C. Institute of Medicine’s Reducing Suicide: A National Imperative

This 2002 Institute of Medicine report highlighted the construct that programs that 

address risk and protective factors at multiple levels are likely to be most effective. In 

addition, the report noted the importance of coping skills as a protective factor. Since 

research suggests that coping skills can be taught, they may therefore be an avenue 

toward prevention.34’

35 Endorsement and implementation of the report is incorporated 

into the VHA Mental Health Strategic Plan. 

D. President’s New Freedom Commission on Mental Health Report Achieving the 

Promise: Transforming Mental Health Care in American

In April 2002, the President’s New Freedom Commission on Mental Health identified 

three obstacles preventing Americans with mental illness from getting the excellent care 

they deserve: (1) stigma that surrounds mental illness, (2) unfair treatment limitations 

and financial requirements placed on mental health benefits in private insurance, and (3) 

the fragmented mental health service delivery system. The President launched the 

Commission to conduct a comprehensive study of the delivery of mental health services 

and to address the problems in the current mental health service delivery system that 

allow Americans to fall through the system’s cracks. In his charge to the Commission, 

the President directed its members to study the problems and gaps and make concrete 

recommendations for immediate improvements that the Federal government, state 

governments, public health care providers, local agencies, and private health care 

providers could implement. 

In its interim report to the President, the Commission concluded that the system is not 

oriented to the hopes of recovery; state-of-the-art treatments, based on research, are not 

being transferred from research to community settings; and in many communities, access 

to quality care is poor resulting in lost opportunities for recovery.36

In submission of the final report to the President, members of the commission wrote that: 

...for too many Americans with mental illness, the mental health services 

and supports they need remain fragmented, disconnected, and often 

inadequate, frustrating the opportunity for recovery. Today’s mental health 

care system is a patchwork relic—the result of disjointed reforms and 

policies. Instead of ready access to quality care, the [American health care] 

system presents barriers that all too often add to the burden of mental 

illness for individuals, their families, and our communities. The time has 

VA Office of Inspector General 12 
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long passed for yet another piecemeal approach to mental health reform. 

Instead the Commission recommends a fundamental transformation of the 

Nation’s approach to mental health care. This transformation must ensure 

that mental health services and supports actively facilitate recovery, and 

build resilience to face life’s challenges. Too often, today’s system simply 

manages symptoms and accepts long-term disability. Building on the 

principles of the New Freedom Initiative, the recommendations we propose 

can improve the lives of millions of our fellow citizens now living with 

mental illness...We look forward to the work ahead to make recovery from 

mental illness the expected outcome from a transformed system of care.37

The Commission identified six intertwined goals as the foundation for transforming 

mental health care in America. For each goal the Commission made recommendations. 

In addition, the Commission urged swift implementation of the NSSP. The ensuing table 

lists Commission goals and recommendations.38 

Goal 1. Americans Understand that Mental Health is Essential to Overall 

Health 

Recommendations 

1.1 Advance and implement a national campaign to reduce the stigma of 

seeking care and a national strategy for suicide prevention. 

1.2 Address mental health with the same urgency as physical health. 

Goal 2. Mental Health Care is Consumer and Family Driven 

Recommendations 

2.1 Develop an individualized plan of care for every adult with a serious mental 

illness and child with a serious emotional disturbance. 

2.2 Involve consumers and families fully in orienting the mental health system 

toward recovery. 

2.3 Align relevant Federal programs to improve access and accountability for 

mental health services. 

2.4 Create a Comprehensive State Mental Health Plan 

2.5 Protect and enhance the rights of people with mental illnesses. 

Goal 3. Disparities in Mental Health Services are Eliminated. 

Recommendations 

3.1 Improve access to quality care that is culturally competent. 

3.2 Improve access to quality care in rural and geographically remote areas. 

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Goal 4. Early Mental Health Screening, Assessment, and Referral to Services 

Are Common Practice. 

Recommendations 

4.1 Promote the mental health of young children. 

4.2 Improve and expand school mental health programs. 

4.3 Screen for co-occurring mental and substance abuse disorders and link with 

integrated treatment strategies. 

4.4 Screen for mental disorders in primary health care, across the life span, and 

connect to treatment and supports. 

Goal 5. Excellent Mental Health Care is Delivered and Research is 

Accelerated. 

Recommendations 

5.1 Accelerate research to promote recovery and resilience, and ultimately to 

cure and prevent mental illness. 

5.2 Advance evidence-based practices using dissemination and demonstration 

projects and create a public-private partnership to guide their implementation. 

5.3 Improve and expand the workforce providing evidence-based mental health 

services and supports. 

5.4 Develop the knowledge base in four understudied areas: mental health 

disparities, long-term effects of medications, trauma, and acute care. 

Goal 6. Technology is Used to Access Mental Health Care and Information 

Recommendations 

6.1 Use health technology and telehealth to improve access and coordination of 

mental health care, especially for Americans in remote areas or underserved 

populations. 

6.2 Develop and implement integrated electronic health record and personal 

health information systems. 

E. Under Secretary for Health’s A Comprehensive VHA Strategic Plan for Mental 

Health Services 

The Under Secretary for Health charged a work group to review the President’s New 

Freedom Commission on Mental Health Report. The work group was tasked with 

determining the relevance of the Commission’s goals and recommendations to veterans’ 

mental health programs and to develop an action plan tailored to the special needs of the 

enrolled veteran population. This work group developed and published an Action 

VA Office of Inspector General 14 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

Agenda in Achieving the Promise: Transforming Mental Health Care in VA, in December 

2003, which generated multiple talking points from the six tenets of the President’s New 

Freedom Commission Report. The VA Action Agenda report, along with work derived 

from the Capital Asset Realignment for Enhanced Services (CARES) process and the 

need to address future geropsychiatric and other needs of the enrolled veteran population, 

prompted the Deputy Under Secretary for Health to task the Office of the Assistant 

Deputy Under Secretary for Health with facilitating the efforts of a workgroup to develop 

a comprehensive, overall strategic plan for mental health care services. The Action 

Agenda recommendations, the Acting Under Secretary’s “12 in 12”E

 plan, and 

recommendations from a VA Mental Health Task Force report entitled “Availability and 

Access to Mental Health and Substance Abuse Services for Veterans,” formed the 

foundation of the work of the Mental Health Strategic Plan Workgroup and the resulting 

MHSP. During this development process, the workgroup conducted meetings with over 

125 experts in mental health. Ultimately the multiple talking points were incorporated 

into a 5-year strategic plan with more than 200 initiatives. The MHSP was initially 

approved by the Under Secretary in July 2004 and was finalized in November 2004.39 

The purpose of the MHSP was to present a new approach to mental health care focused 

on recovery versus pathology and integration of mental health care into overall health 

care for veteran patients. The action plan includes timetables and responsible offices 

identified for each action item. In addition to the President’s New Freedom Commission 

Report, other factors that influenced the MHSP Work Group included the influx of 

OEF/OIF veterans, the challenge to deliver quality mental health services to a growing 

number of women veterans, and the changing and future mental health service needs of 

aging Vietnam Era veterans.40

The following table lists initiatives from the MHSP that pertain to suicide prevention.41

• Develop methods for tracking veterans with risk factors for suicide and 

systems for appropriate referral of such patients to specialty mental 

health care. 

• Develop a plan to educate all staff who interact with veterans, including 

clerks and telephone operators, about responding to crisis situations 

involving at-risk veterans. This would include suicide protocols for 

intake, telephone operators, and other first contact personnel. 

• Develop mandatory education programs for VA health care providers 

about suicide risks and ways to address these risks. Incorporate best 

practices for suicide prevention. 

• Promote evidence based strategies for suicide assessment and 

 

E

 Jonathan B Perlin, Moving from Strategy to Action: 12 Priorities–12 Months, VHA Senior Managers Conference, 

Washington, DC, August 17, 2004. 

VA Office of Inspector General 15 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

prevention including emphasis on special emphasis groups. 

• Develop and test an electronic suicide prevention database. 

• Develop a national systematic program for suicide prevention. 

• Endorsement and implementation of the National Strategy for Suicide 

Prevention (2001) and the Institute of Medicine’s report, Reducing 

Suicide: A National Imperative (2002). 

• Develop a plan for 24-hour mental health care availability through 

VHA. 

• Medical centers establish contacts through the Chaplain Service with 

faith-based organizations and community resources to assist with 

culturally competent suicide prevention and other mental health issues 

at local and national levels. 

• Support for a new Mental Illness, Research, Education Clinical Center 

(MIRECC) with focus on suicide prevention, in collaboration with other 

MIRECC’s working in this area. 

In a section of the MHSP report entitled “Issues in Mental Health Care for Specific 

Populations,” under the heading of “Suicide Prevention,” the report notes: “Another 

mental health focus is on suicide prevention. The VA’s strategy for suicide prevention 

should include universal screening designed to activate the system as a whole for the 

prevention of suicide. Identification of periods of increased risk in veterans known to 

have mental health or substance use disorders is important and targeted interventions 

designed to address the needs of veterans acutely or chronically at increased risk for 

suicide are needed.”42

Identification of periods of increased risk and targeted interventions is effectively 

subsumed in the suicide prevention related initiatives of the MHSP action plan and will 

be discussed under the targeted intervention and screening and referral headings in the 

findings of this report. The context for the phrase “universal screening” reportedly was 

to imply that, in line with the goals of the President’s New Freedom Commission, just as 

psychiatrists should ask patients about any physical concerns and address these concerns 

through appropriate referral or intervention, non-psychiatrists should routinely ask all 

patients, regardless of health care venue (such as surgical or medical), if they are 

experiencing any mental health concerns and should refer or intervene appropriately. 

This “universal” strategy would potentially improve detection of mental illness, reduce 

stigma, enhance patient willingness to pursue treatment and thereby enhance suicide 

prevention efforts. Universal screening of all patients specifically for suicidal ideation or 

risk was not adopted by the MHSP workgroup as an initiative in the MHSP action plan. 

VA Office of Inspector General 16 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

The United States Preventive Services Task Force (USPSTF) has concluded that the 

evidence is insufficient to recommend for or against routine screening by primary care 

clinicians to detect suicide risk in the general population. Screening instruments for 

suicidal ideation are more commonly used in specialty clinics and mental health settings 

but test characteristics of most commonly used screening instruments have not been 

validated to assess suicide risk in primary care settings. The USPSTF found: (1) no 

evidence that screening for suicide risk reduces suicide attempts or mortality; (2) limited 

evidence on the accuracy of screening tools to identify suicide risk in the primary care 

setting, including tools to identify those at high risk; (3) insufficient evidence that 

treatment of those at high risk reduces suicide attempts or mortality [difficult to show 

statistically as the incidence of suicide in the general population (0.1percent) is relatively 

low]; and (4) studies that directly address the harms of screening and treatment for 

suicide risk. As a result, the USPSTF could not determine the balance of benefits and 

harms of screening for suicide risk in the primary care setting. However, the USPTSF 

does recommend screening adults for depression in clinical practices, including primary 

care settings, that have systems in place to assure accurate diagnosis, effective treatment, 

and follow-up.43 

The following sections of this inspection will describe the scope and methodology 

employed to derive information and data used in this evaluation and will assess and 

depict the extent to which VHA has implemented MHSP initiatives for suicide 

prevention. 

Scope and Methodology 

A. Survey of VHA Facilities 

To ascertain implementation of MHSP suicide prevention initiatives at the point of 

service level we developed and conducted a 31-question web based survey. (Appendix A) 

The survey was initially piloted in early December and then distributed to Veterans 

Affairs Medical Centers (VAMCs) between mid-December 2006 and early February 

2007. Surveys were sent to facility Chiefs of Staff to be completed in collaboration with 

clinicians from mental health, primary care, and quality management. The web based 

survey was intended to capture a descriptive on the ground snapshot of implementation at 

the facility level. The questions on the survey were intended to align with various MHSP 

suicide prevention initiatives. 

Survey design included a series of yes/no questions. For several questions in which the 

respondent answered “yes,” follow-up questions asked the respondent to mark applicable 

items or to describe the applicable programs or strategies implemented. This design was 

employed to discourage unsupported “yes” responses and to improve response validity. 

In addition, as we were aware that most or all of the initiatives were not implemented 

system-wide, we included qualitative descriptive items in the survey methodology in 

VA Office of Inspector General 17 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

order to capture an image of pilot sites and/or islands of local innovation. The survey 

was sent to all VISNs. Facilities from 17 VISNs responded. Facilities from four VISNs 

did not respond. Overall, 110 facilities responded to the survey instrument. Responses to 

follow-up questions asking for a brief description of programs/strategies implemented 

were reviewed. These responses were evaluated to gauge whether they aligned with the 

intent of the related index question. 

B. Field Interviews 

From December to February 2007, inspectors conducted interviews with present and 

former VHA mental health leadership, members of the MHSP workgroup, VHA clinical 

researchers at the VISN 3 MIRECC, VISN 4 MIRECC, VISN 19 MIRECC, and the 

newly-formed VISN 2 Canandaigua Center of Excellence. We conducted interviews 

with the Director of the VA’s Readjustment Counseling Service, the Acting Director of 

Primary Care Services, a mental health liaison in the Office of Research and 

Development (ORD), and the Director for the Primary Care & Mental Health Integration 

Program. In addition, we interviewed clinical researchers from the VA Serious Mental 

Illness Treatment Research and Evaluation Center (SMITREC), and the VA National 

Center for Patient Safety. In addition, we reviewed materials from selected VA suicide 

education programs and conferences, and one of the inspectors was an observer at a 

February 7–9, 2007, regional conference “Evidence-Based Interventions for Suicidal 

Persons” co-presented by the VISN 19 MIRECC and the American Foundation for 

Suicide Prevention (AFSP). As we were aware that most of the MHSP initiatives for 

suicide prevention have not reached the level of system-wide implementation, one 

objective of the interview process was to ascertain a panoramic image of the nature and 

extent of implementation for the suicide prevention initiatives. The interview process 

began with an outline by VHA mental health leadership of work in progress. We then 

conducted specific detail oriented interviews with VHA experts in the “trenches” to 

enhance our perspective and understanding of the work being done, to assess the extent 

of progress toward implementation, and as a method for validation. 

This review does not address the financial resources attendant to MHSP suicide 

prevention initiatives. Because the Surgeon General’s National Strategy for Suicide 

Prevention and the IOM report, Reducing Suicide: A National Imperative, are broad 

roadmaps for action to help guide an informed selection of activities for suicide 

prevention, and endorsement and implementation of the NSSP and IOM report are 

incorporated into the MHSP, the scope of this report will focus largely on implementation 

of suicide prevention initiatives unique to the MHSP action plan. The NSSP and IOM 

goals include efforts at improving outreach and reducing stigma. The extent of VHA 

implementation of initiatives related to outreach and reduction of stigma will also be 

reviewed in the findings. 

VA Office of Inspector General 18 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

C. Benchmark Considerations 

An informed assessment of VHA implementation requires a brief discussion of 

benchmark comparisons and challenges to implementing a public health approach to 

suicide prevention. 

1. Suicidologists have struggled with standardization issues for many years. While it 

has long been held that the pursuit of valid and reliable suicide statistics is 

important to public health policy and empirical research, establishing the validity 

and reliability of suicide rates had been a notable source of concern. In the U.S. it 

is widely assumed by mental health professionals that the actual suicide rate is 

significantly higher than officially reported rates. Establishing the validity and 

reliability of suicide rates is complicated by stigma. Other sources of variability 

include limitations of death certificates, variability in the training of those tasked 

with certifying cause of death, use of differing guidelines for suicide 

determination, and the presence of equivocal causes such as drug overdoses, 

single car deaths, jumps/falls, and sexually related asphyxia. There have been 

attempts in the literature to develop operational or empirical criteria for the 

determination of suicide but the challenges persist.44 The fact that the majority of 

veterans receive health care at non-VHA venues complicates the ability to 

establish a reliable rate of veteran suicides in the general population. In terms of 

VHA utilizers, a facility may not become aware of or may experience a lag in 

awareness of an outpatient suicide by a veteran seen at infrequent intervals (for 

example, a relatively healthy veteran who commits suicide between annual 

primary care check-ups). Furthermore, reporting of suicide attempts and 

parasuicidal behavior tends to be subject to greater variability. A percentage of 

attempts never come to the attention of health care providers. In addition, there is 

often a lack of standardization in how health care providers define 

attempts/gestures/parasuicides or when defined, subjective interpretation and a 

lack of uniformity in categorization of attempts.45

2. Although it is the 11th leading cause of death, suicide is relatively infrequent and 

is difficult to track as discussed in the previous section. With 11 suicides for 

every 100,000 people, a very large sample is needed to reach valid conclusions 

using suicide as an outcome measure. Because of the very large sample size 

requirement demonstrating the ultimate impact of target interventions prior to 

implementation is a significant challenge. In addition, the use of number of 

suicides or rate of suicides as a quality outcome measure on the facility level is 

therefore of limited utility in the absence of an abrupt and dramatic trend or shift 

in the data. Suicide attempts are sometimes used as a proxy for completed 

suicides, because attempts are a risk factor for suicide death. As one in ten suicide 

attempters dies by suicide, the utility of attempts as a proxy measure is limited.46

Despite the limitation of completed suicide or suicide attempts as outcome 

measures at the facility level, the use of process measures can help identify 

VA Office of Inspector General 19 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

meaningful gaps in service delivery and can provide opportunities for quality 

improvement. 

3. Some suicidologists suggest that within the realm of self-injurious behavior, there 

are overlapping and clinically distinct groups that include ideators, threateners, 

first time attemptors, chronic, repetitive attempters, deliberate self mutilators, and 

suicide completers. How these groups overlap and what keeps patients from 

moving from one group to another are the work of ongoing research.47 

4. Suicide is not a single illness with one true cause, it is a final common outcome 

with multiple potential antecedents, precipitants, and underlying causes.48 

Interventions most effective for a chronically suicidal patient with borderline 

personality disorder may differ from interventions that are most effective for an 

elderly male with depression and the early stages of Alzheimer’s dementia. 

5. Implementing interventions that target specific at-risk groups, such as the use of 

dialectical behavioral therapy (DBT) for patients with borderline personality 

disorder, requires recruitment and/or training of clinicians skilled in providing this 

mode of treatment. As dissemination of treatment skills takes time and resources, 

clinicians and policy makers are confronted with challenging decisions regarding 

which treatment interventions may be of greatest potential benefit to the greatest 

number of patients or alternatively the highest at-risk patients. 

Clinician researchers generally consider the majority of suicides to be preventable. 

However, prevention of suicide remains a significant challenge. This being said, as 

stated in the 2002 World Health Organization report, Violence—A Global Public Health 

Problem, “...the impulse to invest only in proven approaches should not be an obstacle to 

supporting promising ones.... Violence is far too pressing a problem to delay public 

health action, while waiting to gain perfect knowledge.”49

While the findings of this report could be presented using a binomial “fully 

implemented” versus “not fully implemented” method, this approach would provide little 

new information for relevant stakeholders, and would not fulfill, in a satisfactory manner, 

the task requested of us. Therefore, in order to best present our findings in an accurate, 

objective, and informative manner, we employed a method by which implementation was 

assessed along a spectrum of five stages which we have defined as follows: 

1. No Action – An initiative for which we could not find evidence of plans for future 

development, piloting or implementation. 

2. Planning and Development – An initiative for which we found evidence of 

resource and process planning but which we could not find evidence of piloting or 

local implementation. 

VA Office of Inspector General 20 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

3. Pilot or Demonstration – An initiative for which we found evidence of ongoing or 

completed pilot or demonstration projects. 

4. VISN-Wide Implementation – An initiative for which we found evidence for 

implementation throughout an entire VISN or in multiple facilities in multiple 

VISNs. 

5. System-Wide Implementation – An initiative for which we found evidence for 

implementation throughout VAMCs. 

 IMPLEMENTATION STAGES

System-Wide Implementation 

VISN-Wide Implementation

Pilot Stage

Planning and Development

No Action 

Findings 

Given the breadth of the topic of this report and the extent of information that will be 

provided in the findings, for the purpose of presentation, we have categorized individual 

MHSP initiatives into one of six domains: 

A. Crisis Availability and Outreach 

B. Screening and Referral 

C. Tracking and Assessment of Veterans at Risk 

D. Emerging Best Practice Interventions and Research 

E. Development of an Electronic Suicide Prevention Database 

F. Education 

While we attempted to place each initiative in the most relevant category, some initiatives 

impact on multiple domains. These initiatives are therefore appropriately discussed or 

referenced in multiple sections. 

VA Office of Inspector General 21 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

Under each domain, we discuss several topics. Initially, there is a summary of the results 

from survey related to that topic. Following that, we generally have charts that illustrate 

the survey results we received. In many instances, this is followed by an arrowed bullet 

symbol (Â), which provides information we learned from interviews. 

A. Crisis Availability and Outreach 

Availability 24/7. More than 94 percent of facilities responding to the web based survey 

reported 24-hour availability of mental health care at their facilities. Slightly more than 5 

percent reported lack of 24-hour availability. Ninety-eight facilities reported availability 

through the emergency room/urgent care; 24 facilities reported availability of a walk-in 

clinic; and 34 facilities reported availability of an in-house 24-hour crisis hotline. The 

question was formatted to allow for facilities that have more than one of these options to 

report all options. 

Â In January 2007, JCAHO requirement 15A went into effect, which required that 

patients being treated for emotional or behavioral disorders be assessed to 

determine if they are at risk for suicide and that facilities should follow up 

accordingly. One expectation of the requirement is that organizations provide 

information such as a crisis hotline to individuals and their family members for 

crisis situations.50 In response, VHA issued a policy and procedures guideline for 

JCAHO 15A.F

 At the time of initial interview in early December 2006, OMH 

leadership did not have data on how many facilities had an in-house 24/7 crisis 

 

F

 Under Secretary for Health’s Information Letter, IL 10-2006-013, New JCAHO Performance Requirement for 

Mitigating the Risk of Suicide, December 11, 2006. 

VA Office of Inspector General 22 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

line or arrangements with local community 24/7 crisis lines. Subsequently, the 

OMH internally surveyed VAMCs and reported that VHA is working with 

national and community agency run hotlines, so that if a facility does not have an 

in-house crisis line, patients calling the facility crisis number can be patched to a 

non-VA community or national hotline. The OMH reported working with the 

Substance Abuse and Mental Health Services Administration to ensure that 

existing non-VA suicide prevention hotlines are aware of veteran related issues 

and services. The Readjustment Counseling Service Office reported that patients 

who call Vet Centers at non-working hours are given a number for an area VAMC 

or a community crisis line. “A very early” planning proposal considers possibly 

establishing a manned vet center crisis line in areas where there is not an available 

24-hour VAMC or community line. 

Increased Access. Ninety-nine percent of responding facilities reported that they have 

undertaken efforts to increase access to mental health care and substance abuse services. 

In describing these efforts, several facilities reported increased staffing and recruitment of 

providers, expansion of mental health staff to Community Based Outpatient Clinics 

(CBOCs), implementation of Advanced Clinic Access principles, and integration of 

mental health clinicians into primary care settings. There were multiple innovations 

reported on a facility level. Strategies reported included creation of a Women’s 

Behavioral Health Treatment Clinic in a separate area with a separate waiting room; 

initiation of a “OEF/OIF START” program to assesses newly returned combat veterans 

and assist them with appointments into the mental health clinic; an OEF/OIF Combat 

Stress Group that welcomes walk-ins; establishment of a Mental Health Access and 

Referral Clinic to help place patients in appropriate programs on the day that they request 

service using the “one stop shopping” approach; increased use of open scheduling and 

drop-in assessment clinics; expanded evening clinics; presence and availability of mental 

health professionals at outreach events; and a drop-in medical group for homeless 

veterans, and a Mental Health Intensive Rural Case Management program (“Pony 

Express” model) that is partially integrated with primary care. 

The web based survey asked facilities whether mental health clinicians were co-located in 

primary care clinics. Fifty-six facility respondents endorsed having the presence of 

mental health clinicians at primary care clinics. 

VA Office of Inspector General 23 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

Â One of the more extensive system-wide efforts for improving access (and reducing 

stigma) is the Primary Care/Mental Health Integration Program whereby mental 

health clinicians will be present in primary care venues to treat patients, educate 

and support primary care providers, and educate patients and families. Some 

facilities have implemented locally initiated and developed co-located models for 

the past few years. The nationally directed program began implementation in the 

1st quarter of fiscal year (FY) 2007. Request for proposals went out to facilities in 

May 2006, half were approved in the fall of 2006 and half were sent back to the 

facilities for re-adjustment and re-submission. Between the initial approvals and 

those re-submitted, the program will be implemented in 70–80 facilities. A 

program office and staff were funded and have been recruited. 

Â There are two models for integration. First is the co-located collaborative care

between a mental health provider and primary care physician located in the same 

clinic area or close proximity at the same time. The second is a case management 

model, in which a primary care physician refers patients to a mental health care 

manager, usually a registered nurse, who conducts ongoing phone follow-up with 

patients regarding medication response and adherence, reinforces patient coping 

skills, and provides education to patients and ongoing decision support to the 

primary care physician. Under the co-located model, if a patient screens positive 

on a depression or PTSD screen and the positive screen is supported on primary 

care physician interview, then, if agreeable, the patient could be walked down the 

hallway for an assessment by a mental health clinician that day. When 

appropriate, patients will be referred to mental health clinic. Some patients will 

receive treatment or a short term course of structured therapy at primary care sites. 

The Primary Care Integration Program Office plans to inventory existing programs 

to ascertain what is being done, who is doing it, does it look like the co-located or 

case management model, and how is it working. The program office plans to 

develop performance measures, to host monthly national calls from the 

participating field sites to share best practices and experiences, and to tailor 

capacity to match actual demand at individual sites. 

Increased Awareness. Facilities were asked what efforts have been undertaken to 

promote awareness that suicide is a preventable public problem. Ninety-seven facilities 

described efforts to promote awareness. Several facilities mentioned in house education 

VA Office of Inspector General 24 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

and in-service training for staff. Other local innovations included required reading for all 

nursing staff, outreach to local media to provide veteran and suicide related education and 

facility contact information, display of posters throughout the medical center, and 

creation of a pamphlet, “Recognizing the Warning Signs for Suicide and What YOU Can 

Do,” which will be available to veterans and employees at that VAMC. 

Reducing Stigma. Approximately 85 percent of responding facilities reported 

implementing strategies to reduce the stigma associated with pursuing mental health 

and/or substance abuse treatment. Local strategies described by facilities included the 

use of posters and newsletters; weekly educational classes for patients which teach the 

contribution of genetics and chemical imbalance in substance addiction; making mental 

health programs known to veterans groups in the area; the involvement of a Mental 

Health Consumer Council with a subcommittee focused on reducing stigma; 

establishment of a Peer Advisory Committee; presentations at National Guard and 

Reserve meetings and an agreement with National Guard leadership in one state to speak 

with returnees on a one-to-one basis to address stigma; and involvement in a Mental 

Health Awareness program with presentations by the state chapter of the National 

Alliance for the Mentally Ill (NAMI), veteran consumers of mental health care, and a 

member of Congress. 

Â The OMH has emphasized transformation to a recovery model for patients with 

the seriously mentally ill (SMI) population in line with the philosophy of the 

President’s New Freedom Commission Report. OMH has funded development of 

Psychosocial Rehabilitation (PSR) programming and positions for facility 

recovery coordinators to help coordinate efforts toward recovery and destigmatization. Psychiatric research indicates that patients with serious mental 

illness may be at greatest risk for suicide in the few years following initial 

diagnosis. PSR programming emphasizes moving from a focus solely on patient 

symptomatology to a focus on one’s level of function in the world. PSR promotes 

the use of environmentally specific skills, strengths, and abilities to aid in reintegration and function within the community. By addressing stigma and 

focusing on function, the recovery model is aimed at fostering hope for the future 

rather than expectations of disability and chronicity. 

VA Office of Inspector General 25 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

Community Based Prevention. One fifth of facility respondents reported implementing 

community based suicide prevention programs. Descriptions of innovations implemented 

by local facilities included a relationship with the New York Police Department (NYPD) 

with presentations to NYPD officers who are OEF/OIF veterans in an attempt to destigmatize pursuing care for mental health symptoms and issues that may arise; QPRTMG

gatekeeper training for Community Residential Care (CRC) sponsors, VA licensed 

Family Care Home and Personal Care Home providers, and upcoming QPRTM gatekeeper 

training for parents and teachers at a local school; involvement in Crisis Intervention 

Team Training education for member of the Memphis Police Department; distribution of 

educational DVD’s on young adult suicide to local schools and colleges; participation by 

mental health staff in local Spanish language radio and television shows; education to 

reservists on weekends; and participation in a Colorado Brain Injury Association exhibit 

and presentation regarding TBI patients. 

Â The Director of the VA Readjustment Counseling service reported that Vet 

Centers have made 134,760 cumulative outreach contacts to OEF/OIF veterans 

through June 2005. He reported that vet center personnel conduct information 

sessions at demobilizations all around the country. He emphasized an outreach at 

a New Hampshire National Guard base “to welcome them home; to give literature; 

to say we are like you.” He reports that 2 weeks later, vet center personnel 

screened 800 guardsmen at the base by interview and let them know “if you need 

us we are here.” He reports that 15 percent initially stated that they wanted help. 

Involving Chaplains. Less than 20 percent of responding facilities reported utilizing 

VHA’s Chaplain Service to establish contacts with faith-based organizations and 

community resources. Locally initiated strategies implemented at select VAMCs included 

inviting faith-based organizations in the Richmond area to a community meeting at the 

VAMC to explain hospital services available and for organizations to explain their 

services to VAMC participants; working with Vermont National Guard chaplains to 

assist with mental health issues; accompanying the OEF/OIF coordinator to all postdeployment events in the community; meeting with a group of local clergy to discuss 

ways in which VAMC chaplains may be of assistance; providing education programs at 

local denominational, local church, and city-wide pastoral meetings; and providing 

education on veteran mental health to clergy students from a local Clinical Pastoral 

Education training program. 

 

G QPRTM stands for Question, Persuade, and Refer – an emergency intervention undertaken upon recognizing 

suicide warning signs in someone known to the QPR-trained person. 

VA Office of Inspector General 26 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

Â Planning and developing an education program designed to optimize chaplain 

awareness of mental health issues and how to access appropriate mental health 

care is under consideration by the OMH. Potentially, the Chaplain Service could 

be trained for use as a resource to educate community chaplains, and in turn could 

educate mental health providers regarding spiritual issues that affect patient care. 

At present we could not find evidence of centrally guided implementation beyond 

pre-planning discussion and tentative planning. 

Conclusions Regarding Crisis Availability and Outreach. In terms of MHSP 

initiatives related to the availability of crisis care and outreach, the extent of 

implementation by VHA can be summarized as follows: 

1. Most facilities reported availability of 24-hour mental health care either through 

the emergency room, a walk-in clinic or a crisis hotline. However, available 24-

hour mental health care has not achieved full system-wide implementation. In 

addition, although facilities in multiple VISNs have or refer to external 24-hour 

crisis hotlines, availability of a 24-hour crisis hotline is not yet universal 

throughout the system. 

2. Most VAMCs have undertaken efforts locally to increase access to mental health 

and substance abuse services. It is anticipated that implementation of the primary 

care-mental health integration program at multiple sites in multiple VISNs will 

increase and/or expedite access to mental health and substance abuse services. At 

present co-location exists at several sites and a significant increase in sites is in 

process of implementation. 

3. Overall, most VAMCs have implemented local strategies to reduce stigma. In 

addition, the Readjustment Counseling Service has undertaken significant 

outreach to returning veterans throughout the country. The Office of Mental 

Health Services has implemented transition to recovery and hope based 

programming for the Seriously Mentally Ill. PSR programming is in place in 

multiple VISNs and system-wide implementation is in process. 

4. Many facilities have implemented innovative community based outreach/suicide 

prevention programs, although the majority of facilities did not report community 

VA Office of Inspector General 27 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

based linkages and outreach. As local community demographics, needs, and 

resources differ, local strategies may be more appropriate then universal, centrally 

driven strategies for this purpose. 

5. Less than 20 percent of facilities reported utilizing the Chaplain Service for liaison 

and outreach to faith based organizations in the community. 

B. Screening and Referral 

Screening. In-depth, face to face, clinical interview remains the best way to screen and 

assess for suicide risk. At present, a widely accepted and effective suicide screening tool 

does not exist, partly because of the complexities associated with the phenomena of 

suicide. Though there are some underlying commonalities, suicide and suicide attempts 

result from the complex interaction of a constellation of biological, psychological and 

social factors that manifest themselves within specific cultural and situational contexts. It 

has therefore been difficult for researchers to develop a proven screening tool that 

captures this disparate phenomenon, reliably and efficiently, for use in a heterogeneous 

veteran population. 

Depression, PTSD, and substance abuse are mental health conditions associated with 

increased suicide risk. Annual screenings for depression, PTSD and substance abuse at 

primary care clinics are performance indicators used by VHA. Not surprisingly, 98 

percent of facilities reported at least annual screening for depression and problem 

drinking and/or substance abuse in primary care clinic. Slightly less, or 93 percent of 

facility respondents indicated at least annual screening for PTSD at primary care clinic. 

The reason for the slight difference (approximately six less facilities), was unclear. 

Facilities were asked who generally administers screenings. The question was set up to 

allow for multiple responses. Respondents reported that at most sites screenings are 

administered by a clinic nurse, physician, and/or nurse practitioner/physician assistant. A 

psychologist and/or mental health nurse administers screenings at slightly less than 

one-fourth of facilities, and a nursing aide/primary care tech at one-third of facilities. 

One facility spontaneously indicated that a social worker does PTSD screening for 

OEF/OIF patients. 

VA Office of Inspector General 28 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

Â Screening tools are being developed and tested at the VISN level. As will be 

discussed in greater detail in the tracking and monitoring section of this report, 

VISN 3 facilities have been using a suicide assessment template that is 

incorporated into the electronic medical record. The template is administered to 

mental health and emergency room patients. A modified version of the VISN 3 

template is being used as part of the mental health intake in VISN 19. 

Â Since patients who suffer TBI may experience increased impulsivity which can 

affect suicide risk, at the Denver VAMC TBI patients are reportedly asked about 

suicidal ideation at Physical Medicine and Rehabilitation clinic follow-up visits. 

Â Chronic unremitting pain is associated with an increased risk for suicide. At the 

Denver VAMC and some other sites in VISN 19, patients seen at chronic pain 

clinic are asked verbal suicide screening questions. Patients identified as at risk 

are referred for specialty mental health care. 

Tools for Screening. Fifty-one responding facilities indicated that primary care 

providers utilize tools for recognition and screening of patients for suicidality. Nineteen 

facilities reported use of standardized clinician-administered instruments, 14 reported use 

of the EES suicide risk assessment pocket card, and 11 reported use of a patient self 

report questionnaire. Other responses included use of a suicide lethality check list, a 

positive depression screen clinical reminder, and use of a clinical reminder that includes 

risk factors. 

Hierarchical Strategy. Survey respondents were asked whether primary care providers 

utilize a hierarchical strategy to follow up positive depression screens with additional 

inquiries about suicidality. Approximately 42 percent of facilities reported using a 

hierarchical strategy of some kind. Of these 46 facilities, 32 reported asking about 

hopelessness, 19 about helplessness, 19 about passive death wishes, 12 about 

hallucinations or delusions, 20 about preoccupation with death, 39 about suicidal ideation 

without plan, and 37 about suicidal ideation with plan. A few facilities reported that all 

of the above queries are included in a link to a depression screen template under 

development. Some facilities reported that primary care providers also follow up with 

questions about recent interpersonal loss, insomnia and access to a method of suicide. 

One facility reported use of a tool comprised of three sections. The first section lists 32 

risk factors that can be checked off. The second section lists a hierarchical set of 

VA Office of Inspector General 29 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

questions used such as “Do you ever wish when you go to bed that you wouldn’t wake 

up, etc.” The third section is a patient self rating of risk for killing themselves on a scale 

of 1–10. Clinicians are reminded to pay attention to inconsistencies in patient responses. 

This tool then indicates appropriate intervention based on combination of responses to the 

three sections. 

Improving Referral. Facilities were asked whether they have implemented a system to 

facilitate referral of veterans with risk factors for suicide by primary care providers to 

specialty mental health care. Approximately 84 percent of facilities indicated a positive 

response. Facilities were asked to describe salient aspects of referral systems in place. 

Several facilities reported service agreements between primary care and mental health for 

same-day psychiatric evaluation. Several facilities responded that a patient who reports 

suicidal ideation is escorted to the acute psychiatry walk-in clinic for evaluation by a 

mental health professional. Some facilities cited local suicide related medical center 

memorandum or policies. 

Innovative strategies reported by facilities include forwarding of all positive depression 

screens to the psychology service, and referral of all positive suicide screens for same day 

evaluation by a mental health crisis worker; a dedicated pager carried by mental health 

clinicians who will see patients for positive depression screens, PTSD screens and/or 

suicidal ideation; use of a screen for suicide risk factors resulting in a same day mental 

health consult for positive screens; use of a pop up screen with protocol that informs the 

provider to accompany actively suicidal patients to the emergency room for psychiatric 

evaluation. Essentially all but one facility reported same day mental health evaluation 

when a primary care provider detects a patient at risk for suicide. A few respondents 

VA Office of Inspector General 30 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

indicated the average length of time from referral would also depend on perceived level 

of risk and patient’s clinical state. 

Time to Evaluation. In order to ascertain a snapshot of time from referral to mental 

health evaluation for other mental health conditions, facilities were asked when a primary 

care provider refers a patient with symptoms of moderate severity and what is the average 

length of time before a patient is seen by a mental health provider for depression, PTSD, 

or substance abuse. It was assumed that responses for patients with severe symptoms 

would mirror those indicated for the previous section. In addition, we would expect lag 

time between referral and appointment for patients with mild symptoms to be variable 

and of unclear clinical relevance if the lag time was within some acceptable outer limit. 

Because patients with moderate symptoms may be progressing toward severe symptoms 

and/or the onset of suicidal thoughts, we felt that time to evaluation was most salient for 

this group. 

Referral for Depression. For depression, 40 percent of facilities responding to the 

survey reported on average same day evaluation by a mental health professional when a 

primary care provider refers a patient with symptoms of moderate severity, 16 percent 

reported less than 1 week, 16 percent reported 1–2 weeks, and 25 percent reported 2–4 

weeks. Five facilities reported a 4–8 week wait. (Note that the symbol < means “less 

than” and > means “greater than.”) 

Referral for PTSD. For PTSD, 34 percent of facilities indicated patients are seen by a 

mental health professional within the same day, 17 percent within 1 week, 17 percent 

within 1–2 weeks, and 26 percent within 2–4 weeks. Six facilities reported a 4–8 week 

wait. 

VA Office of Inspector General 31 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

Referral for Substance Abuse. Forty-two percent of facilities reported that patients 

were seen by a mental health professional within the same day when a primary care 

provider refers patients for substance abuse. Twenty-four percent of facilities reported 

patients are seen in less than 1 week, 14 percent reported a 1–2 week period, and 

18 percent a 2–4 week period. Three facilities reported a wait of 4–8 weeks. The 

reason(s) for the slightly lower times to be seen for substance abuse are unclear but may 

reflect a greater demand for PTSD and Depression evaluation, or the number of available 

substance abuse counselors relative to available psychiatrists, psychologists, and clinical 

social workers. 

Conclusions Regarding Screening and Referral. In terms of MHSP initiatives related 

to screening and referral, the extent of VHA implementation can be summarized as 

follows: 

1. Although the USPTSF does not recommend screening of all primary care patients 

for suicidal ideation, screening for depression by primary care providers is 

recommended in practices that have systems in place to assure accurate diagnosis, 

effective treatment and follow-up.51 VHA has implemented system-wide 

screening by primary care providers for depression, PTSD, and substance abuse. 

VA Office of Inspector General 32 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

2. At least one VISN has implemented suicide screening of patients seen at TBI and 

chronic pain clinics, as these patients represent at-risk groups from an 

epidemiologic standpoint. 

3. Several facilities reported local strategies to address positive depression screens 

with additional inquiries. Centrally, VHA has recently completed revision of a 

pocket card tool which it expects to disseminate system-wide. 

4. Most facilities reported development of local strategies to facilitate referral of 

veterans with risk factors to mental health care. Co-location as previously 

referenced is also aimed at facilitating referrals. 

5. While most facilities self-reported that three-fourths of those patients with a 

moderate level of depression who are referred by primary care providers are seen 

within 2 weeks of referral, a small percentage (approximately 5 percent) reported a 

significant 4–8 week wait. Similar numbers were reported for PTSD and 

substance abuse services. 

C. Tracking and Assessment of Veterans at Risk 

Tracking At-Risk Veterans. A comprehensive suicide prevention program must not 

only be able to identify those at risk for suicide but ideally should identify periods of 

increased risk and should have a method for tracking at-risk patients to ensure that they 

receive timely and appropriate care. About 30 percent of the facility responders reported 

electronically tracking veterans at risk for suicide. Approximately one-fourth reported 

tracking veterans through the electronic medical record while another 5 percent said that 

they were using other methods to track at-risk veterans. 

Tracking Periods of Increased Risk. One reason for tracking at-risk patients is to 

increase the likelihood of intervening in periods of increased risk. Fifty percent of 

responding facilities reported having implemented strategies to target periods of 

increased risk for suicide. The majority of these facilities reported increasing frequency 

of visits, utilization of intensive outpatient treatment groups, and increased phone 

VA Office of Inspector General 33 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

contacts during acute periods of increased risk. One facility reported ascertaining the 

anniversary of traumatic events in the initial psychosocial assessment, and then 

incorporating this information into the individual treatment plan. Integral to targeting 

periods of increased risk is the systematic identification of these periods in individual 

patients. 

Â In January 2005, the VISN 3 MIRECC began installation and testing at a VAMC 

of evidence based suicide risk assessment that has been programmed as a note 

template with drop down supporting materials within the Computerized Patient 

Record System (CPRS). The template is linked to the alerts section and clinical 

reminders in CPRS. The template is based on a stress-diathesis model of 

suicidality. The stress-diathesis model proposes that suicidal behavior is attributed 

to the coincidence of stressors, (such as onset of a depressive episode or anxiety, 

the end of a relationship, unaddressed pain, or alcohol use) with a diathesis, or 

predisposition, for suicidal behavior. According to this model, only persons with a 

susceptibility to suicidal behavior are at risk of attempting to take their own lives 

after exposure to a stressor(s). Pessimism, aggression/impulsivity, and suicidal 

intent have been identified as three elements of the diathesis for suicidal behavior. 

These diathesis factors are due to genetic and/or environmental causes. Research 

studies of suicide completers and attempters have provided some evidence linking 

serotonin related dysfunction predominantly in a particular area of the brain 

(ventromedial prefrontal cortex) involved in executive function and decision 

making, with this susceptibility. In this model, suicide risk factors can be 

categorized as either diathesis (trait) related or (state) stress-related. If suicidal 

behavior occurs as the outcome of stress-diathesis, then management of suicidal 

patients necessitates both identifying and addressing stressor(s) and instituting 

treatment that attempts to reduce the diathesis.52’

53’54

This evidence based risk assessment template prompts the clinician regarding 

longstanding chronic trait-like risk factors, acute state-like risk factors, risk factors 

that have triggered previous suicidal behavior, access to means, and 

mitigating/protective factors. The electronic suicide template and tracking system 

classifies patients into high, medium and low suicide risk categories. Attention to 

high risk patients is linked to alerts and clinical reminders. The VAMC test site 

VA Office of Inspector General 34 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

began using the template for all new mental health and emergency room patients. 

By November 2006, the suicide template was being routinely administered to all 

new mental health patients and all emergency room patients in the VISN. 

MIRECC clinician-researchers are currently collecting data about the efficacy and 

effectiveness of the electronic suicide template and tracking system as a suicide 

prevention tool. After collection and analysis of sufficient data, mental health 

leadership and MIRECC researchers will determine the desirability and feasibility 

of expanding use of the suicide template to primary care and all new patients in 

VISN 3. 

Â In 2005, an electronic suicide registry for suicide attempters and suicide 

completers was implemented at a VAMC in VISN 19. In 2006, the registry was 

extended to all facilities in VISN 19. The registry contains 34 variables related to 

suicides and suicide attempters. The registry details the history and constellation 

of circumstances surrounding each suicide, or suicide attempt and allows for 

following trends. At present, the registry is linked to CPRS. When an attempt 

occurs, a provider completes the suicidal behavior template which consists of drop 

down items. A clinician-researcher at the MIRECC pulls the completed templates 

for the VISN and inputs the data into the registry. When a patient subsequently 

presents for an appointment at a VAMC and a provider opens the electronic 

medical record and clicks on the clinical progress note section, the completed 

suicidal behavior template will be listed and available for review. The presence of 

the suicidal behavior template and its content are intended to alert the provider to 

the potential need for heightened monitoring. The VISN chose to place the 

MIRECC in the clinical notes section in order to avoid “clinical reminder fatigue.” 

Â Preliminary analysis of the data from the registry has provided some insights with 

implications regarding delivery of care. For instance, the data reportedly showed 

that 20 percent of the veterans in the registry had not accessed mental health 

services and did not have a psychiatric history, or diagnosis, at the time of their 

suicide, or suicide attempt. This underscores the importance of clinician 

awareness, mental health screening and outreach to veterans in non-mental health 

settings. In the past 2 months, the VISN 19 registry for suicides, and suicide 

attempters, was implemented for testing in a VA facility in VISN 2, and its use is 

currently being expanded to include all facilities in that VISN. 

Case Managers. Facilities were asked if a case manager has been dedicated specifically 

for the care of patients identified by providers as high risk for suicide. This is not a 

specific initiative from the MHSP but is a potential targeted intervention, consideration of 

which had been recommended in the 2004 Suicide Prevention Work Group report. Ten 

responding facilities indicated having a dedicated suicide prevention case manager. 

VA Office of Inspector General 35 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

Â OMH leadership has reported plans to place suicide coordinators at each facility in 

2007. Coordinators will maintain a case-load for case management of at-risk 

veterans. Final position descriptions are presently still under development and not 

yet determined. The additional comments section to the web survey does appear 

to indicate forward progress toward implementation of this suicide prevention 

strategy. We did not specifically ask facilities about funding or recruitment of 

suicide case managers, but in an additional comments section to the web survey, 

three facilities spontaneously indicated that a suicide prevention coordinator 

position had been funded, a position was being posted, and recruitment was 

underway. 

Â One VHA project involves the use of health buddies. These small electronic 

appliance devices have been given to those enrolled in a study of patients with comorbid pain, depression, and substance use issues. The device routinely sends the 

patient reminders or messages. For example, the device may ask “what was your 

blood sugar today” or “are you feeling down today; if you are please call.” The 

patient records a response to the question which is monitored by someone at the 

facility who, depending on the nature of the query and response, is responsible for 

calling the patient within 24 hours to follow up. At present the queries in the pilot 

study involve mood but not suicidality or suicide risk factors. Queries on 

suicidality may be used in future pilots. Mental health leadership reports that the 

process of being queried itself may have secondary effects. For example, a few 

anecdotal cases were cited in which patients later reported having had suicidal 

thoughts but having dismissed acting on those thoughts after receiving a health 

buddy prompt. 

Â Based on other inspections performed by the OIG’s Office of Healthcare 

Inspections, we are aware of ongoing challenges to the bi-directional exchange of 

information between VA and Department of Defense (DoD) facilities for patients 

with mental illness. 

Conclusions Regarding Tracking and Assessment. In terms of MHSP initiatives 

related to tracking of at-risk patients, the extent of VHA implementation can be 

summarized as follows: 

VA Office of Inspector General 36 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

1. A thorough evidence based risk assessment tool, electronically linked to CPRS has 

been piloted for emergency room and mental health patients in VISN 3. By its 

design, the tool targets identification of at-risk groups and periods of increased 

risk. 

2. Prior suicide attempts are one of the better predictors of at-risk patients. An 

electronic registry of suicide attempts linked to CPRS progress notes has been 

piloted and tested in VISN 19 and recently began pilot testing in VISN 2. 

3. The Office of Mental Health Services is in the process of implementing suicide 

case managers at all VAMCs. 

D. Emerging Best Practice Interventions and Research 

Programmatic, psychotherapeutic, and pharmacologic interventions are presented in this 

section to report on VHA progress in development and implementation of suicide 

prevention strategies and initiatives and to provide the reader with background 

information on specialized interventions in development, pilot or demonstration stages. 

This discussion should not be construed as an OIG endorsement of any particular 

individual strategy or intervention. 

Suicide Prevention Strategies. VAMCs were asked whether specific suicide prevention 

strategies have been implemented to target special emphasis groups (such as OEF/OIF 

veterans, veterans with bipolar disorder with mixed states, and patients with borderline 

personality disorder). Slightly more than one-third of responding facilities indicated 

implementation of suicide programs targeting special emphasis groups. 

Some interventions reported by individual VAMCs included screening returning 

OEF/OIF veterans and patients experiencing MSTT

 

H at each mental health visit; increased 

contacts for OEF/OIF, elderly, and substance abuse patients; monitoring OEF/OIF 

patients for suicide risk factor criteria, monitoring these patients for “no shows” at 

appointments, and subsequently initiating follow-up phone contact; specific groups for 

patients with bipolar disorder who experience mixed states; trained case managers for 

bipolar patients who monitor for periods of increased risk such as mixed states; and a 

H Military Sexual Trauma. 

VA Office of Inspector General 37 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

Women’s Sexual Trauma Team that utilizes strategies like “Seeking Safety” with their 

patients. 

Â “Seeking Safety” is a present-focused therapy. Key principles of “Seeking Safety” 

are safety as the goal of the first stage of treatment; simultaneous, integrated 

treatment of PTSD and substance abuse; a focus on ideals to counteract the loss of 

ideals in both PTSD and substance abuse; cognitive, behavioral, interpersonal and 

case management content areas; and attention to therapist processes for example 

balancing praise and accountability. Eleven completed studies, 7 pilot studies and 

4 controlled studies have been completed utilizing “Seeking Safety” in veteran and 

non-veteran groups. In VISN 1“Seeking Safety” has been piloted in a study of 

women veterans and a study of homeless women veterans.55 

Â Bipolar disorder is an affective disorder. Patients with bipolar disorder type I may 

experience prolonged periods of pervasive elevated mood, depressed mood or 

mixed states in which patients concomitantly experience the increased energy and 

restlessness of a manic phase with the dysphoria of the depressed phase of the 

illness. In general, patients with affective disorders (such as major depression and 

bipolar disorder) are at increased suicide risk. Mixed states are thought to 

represent a period of increased risk for suicide in patients with bipolar disorder. 

There is some evidence that case management helps sustain a more stable course 

in patients with bipolar disorder. It is hoped, therefore, that fostering symptom 

stability will bolster and impact suicide prevention. Office of Mental Health 

leadership reported funding a program to pilot case management for bipolar 

disorder patients at risk at eight sites. 

Based on other inspections performed by the OIG’s Office of Health Care Inspections 

during the last few years, we are aware of ongoing issues concerning admission criteria to 

specialized inpatient mental health programs for returning veterans with concurrent mental 

health and alcohol use issues. In the ideal situation, psychiatric symptoms and 

psychological issues are most effectively addressed during a period of sustained sobriety, 

when the patient can attend closely to the symptoms and issues. Admission criteria to 

specialized programs based on the expectation of sustained sobriety may be appropriate for 

the care of older veterans who have extended periods of chronic, mental health and comorbid substance abuse issues. However, such expectations seem out of step with the 

pragmatic reality of many of the young, returning OEF/OIF veterans who present to VA 

facilties currently. 

Cognitive-Behavioral Therapy. Facilities were asked about the availability of a 

specialized form of cognitive-behavioral therapy (CBT) focused on a suicide prevention. 

CBT is a structured, time limited, directive and change oriented form of psychotherapy 

that emphasizes the important role of thoughts and assumptions in guiding how we feel 

and what we do. Approximately 65 percent of facilities reported availability of CBT 

specifically focused on suicide prevention. The intent of the question was to gauge 

VA Office of Inspector General 38 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

implementation of a specialized modified version of CBT that has been tailored for use in 

suicidal patients. From our review of recent psychiatric literature we were aware that a 

specific type of CBT tailored for suicide prevention has been developed and piloted in 

non-VA studies by clinician-researchers at the University of Pennsylvania Center for the 

Treatment and Prevention of Suicide. We believe the response to this item reflects a 

methodological flaw in how the question was asked. Facilities appear to have based their 

responses on whether they offered any type of CBT since therapists may work with 

patients to address suicidal thoughts in the course of sessions regardless of the form of 

CBT utilized. 

Â Because suicide attempts are one of the more salient risk factors for suicide, 

prospective studies using cognitive therapy for suicide prevention have focused on 

suicide attempters. Underlying constructs for the development of a tailored 

cognitive therapy approach is the assertion that usual treatment for depression may 

not necessarily focus on suicide relevant cognitively mediated processes such as 

hopelessness, and reducing impulsivity, may not address other modifiable risk 

factors, and may not directly help patients develop skills to manage suicidal crises 

in the future. Researchers at the University of Pennsylvania recruited consenting, 

adult emergency department patients who had attempted suicide 48 hours prior to 

presentation at an emergency department, to participate in a randomized study, 

comparing a brief cognitive intervention with usual care. The purpose of the study 

was to determine if a brief course of this suicide targeted intervention would be 

effective in preventing repeat attempts, reducing the severity of established 

modifiable risk factors and increasing use of appropriate health services. In a 

study published in a 2005 issue of the Journal of the American Medical 

Association, these researchers reported no significant difference between groups 

based on suicidal ideation at any given assessment point, however, the CBT group 

had a significantly lower re-attempt rate, diminished severity of self-reported 

depression on the Beck Depression Inventory II, and less self reported 

hopelessness on the Beck Hopelessness. Consultants from the University of 

Pennsylvania are working with the VISN 19 MIRECC, where a pilot study for VA 

patients is starting in FY 2007. Training of select therapists from VISN 19, VISN 

4, and VISN 3 to learn this form of CBT is planned for April 2007 and this 

intervention will be subsequently piloted in VISN 19.56’

57

Â The Collaborative Assessment and Management of Suicidality (CAMS) is a novel, 

comprehensive, multidisciplinary clinical assessment, planning, and clinical 

management approach aimed at reducing suicidal thoughts, feelings, and 

behaviors in outpatient settings developed by a clinician-researcher at The 

Catholic University of America in Washington, DC. CAMS is designed to 

provide an alternative to traditional risk factor and purely diagnostically-driven 

approach to suicide. Key aspects of CAMS are collaborative completion by 

patient and therapist of a structured “Suicide Status Form,” emphasis on a form of 

VA Office of Inspector General 39 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

clinical care and management that is suicide specific, and a means to identify, 

assess, track and document suicidal risk throughout a course of treatment. In 

contrast to a traditional therapist directed symptom focused approach (such as 

insomnia, low mood, or low energy), in CAMS the therapist and patient 

collaboratively assess risk. Targeting suicide is the focus of treatment. 

Underlying issues such as pain, stress, agitation, hopelessness, self-hate, and 

reasons for living vs. reasons for dying are collaboratively assessed. In a 12-

session treatment (CAMS-PST), collaborative assessment and treatment planning 

is followed by collaborative deconstruction of suicidogenic problems (relationship 

issues, vocational issues, self-related issues, pain and suffering), collaborative 

problem-solving interventions and development of reasons for living and 

protective factors. Research with CAMS includes empirical data from work done 

with the United States Air Force 10th Medical Group and work done by a Catholic 

University research team with Johns Hopkins University Counseling Center 

students. In April, the first large randomized controlled trial of CAMS-PST is 

scheduled to begin in VISN 19.58’

59

Dialectical Behavioral Therapy. One half of responding facilities reported availability 

of dialectical behavioral therapy (DBT) for treatment of patients with borderline 

personality disorder. 

Â Personality disorders are estimated to be present in more than 30 percent of 

individuals who die by suicide. In clinical populations, the rate of suicide of 

patients with borderline personality disorder is estimated to be between 8–10 

percent which is a much greater rate than in the general population. Sixty to 70 

percent of patients with borderline personality disorder make suicide attempts, and 

unsuccessful attempts are therefore far more frequent than completed suicides in 

these patients. Co-morbidity of borderline personality disorder with depression 

and substance abuse has been well documented in the literature.60 DBT is a 

cognitive-behavioral therapy designed for severe and chronic difficult to treat 

patients. DBT grew out of an iterative attempt to apply cognitive-behavioral 

therapy to the problem of treating suicidal behavior. DBT applies a dialectical 

(synthesis between two contradictory ideas) approach that attempts to balance 

change/problem solving with acceptance/validation. The extremes in thinking 

(often times an all-or-nothing paradigm), behavior, emotional states, and 

relationships experienced with borderline personality disorder makes DBT 

particularly relevant as a potentially promising treatment for these patients. DBT 

attempts to move patients from an either-or to a both-and framework. Researchers 

have studied the use of DBT in non-VA populations.61 The VISN 4 MIRECC has 

held DBT workshops and a regional conference in 2006 with a breakout session 

for VISN 3 and 4 clinicians. DBT groups are offered at several VHA facilities. 

VA Office of Inspector General 40 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

Lithium Treatment. Survey respondents were asked to estimate the approximate 

percentage of newly diagnosed patients with bipolar disorder type I who have been 

prescribed the mood stabilization agent lithium in the past 24 months. Forty-five percent 

of facility respondents reported less than 10 percent utilization, approximately one-fourth 

of facility respondents reported 10–25 percent utilization, and slightly under one-fourth 

reported 26–50 percent utilization. 

Â In the psychiatric literature, lithium has been reported to have a specific antisuicide effect for patients with mood disorders. In addition to its use as a mood 

stabilizing agent, there are randomized, controlled trials indicating that adding 

lithium to augment antidepressants may reduce symptoms in patients with unipolar 

depression who have incompletely responded to antidepressants alone. Despite 

these potential benefits, lithium use in VA and non-VA settings has been declining 

for several years. Reasons for this are unclear but may be due to concerns about 

safety, need for monitoring blood levels, tolerability, potential side effects, and 

stigma.62’

63

Clozapine Treatment. To a similar question, in which VAMCs were asked to estimate 

the percentage of patients with schizophrenia who have been offered treatment with the 

antipsychotic medication clozapine over the past year, 90 percent of responding facilities 

reported less than10 percent utilization and 7 percent reported 10–25 percent utilization. 

VA Office of Inspector General 41 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

Â The completed lifetime suicide rate in schizophrenia is 4–13 percent. Suicide 

remains the leading cause of death among patients with schizophrenia under 35 

years of age. In addition, the lifetime suicide attempt rate is 25–50 percent with 

40 percent of attempters making their first attempt with the first year of psychosis. 

One-third of completed suicides among patients with schizophrenia occur after the 

age of 45. It is unclear whether suicide among these patients is a measure of 

untreated psychosis or a separate domain of psychopathology. There is psychiatric 

literature to suggest that clozapine is particularly effective in patients with 

schizophrenia who have had refractory responses to antipsychotic medication. In 

addition, studies such as the 2003 InterSePT study indicate a potential benefit of 

clozapine in respect to suicide attempts.64’

65 As with lithium, the low utilization 

for treatment of psychosis in the VA system also reflects the low utilization in 

non-VA community mental health settings and is not unique to the VA system. In 

response to the low utilization rate, the VISN 3 MIRECC has developed a 

clozapine education and consultation program to increase indicated usage 

throughout VISN 3 and ultimately VHA.66

Other Interventions. Other emerging best practice interventions include: 

Â PSR programming, which was discussed in a previous section of this report, 

beginning on page 25. 

Â The primary care-mental health integration program discussed in a previous 

section of this report. In addition, to potential mitigation of stigma, enhanced 

mental health access and care coordination, integrated sites could be particularly 

beneficial to targeting older veterans. A non-VA study using a care management 

model showed benefit in treating older adults with major depression and in 

particular, a sub-group of depressed, elderly diabetic patients. The SAMHSAI

-VA 

 

I

 SAMHSA is the Substance Abuse and Mental Health Services Administration, an organization of the Department 

of Health and Human Services. 

VA Office of Inspector General 42 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

PRIMEJ study67 showed a greater engagement in care among patients with 

depression, anxiety, and at-risk drinking for elderly patients treated in the 

integrated setting versus referral to mental health. In the non-VA Prospect 

study,68 those who got care in primary care practices with mental health 

availability had a lower all cause mortality. 

Â The NCPS has completed a review of RCA’s for all inpatient suicide and 

parasuicide attempts from 1999–2006 in an effort to better understand the methods 

and environmental factors involved in inpatient suicide attempts in VA hospitals. 

This data will be used to make some recommendations for environmental 

interventions intended to reduce inpatient suicide and diminish parasuicide 

behaviors.69

Â Through our interviews and observations during the course of this inspection, it 

was clear that the VISN 19 MIRECC—whose focus is on suicide prevention—is 

operational, a leader in suicide prevention clinical research within VA, and 

collaborates extensively with other MIRECC’s working in this area. During the 

course of the inspection, it also became apparent that VHA mental health 

leadership actively promotes research on suicide and suicide prevention. 

Conclusions Regarding Emerging Best Practice Inverventions and Research. In 

terms of MHSP initiatives related to emerging best practice interventions, the extent of 

VHA implementation can be summarized as follows: 

1. Therapies and strategies that target patients at acute and chronic risk for suicide 

and have appeared promising in research from non-VA settings have been 

developed, piloted, and tested in select VISNs. Other potentially promising 

suicide specific strategies and therapeutic interventions are presently in or 

beginning pilot testing in VISN 19. 

2. Some promising therapies targeted at higher risk patients, (for example, DBT for 

patients with borderline personality disorder) are locally offered at several 

facilities. 

3. System-wide implementation of PSR programming targeting patients with serious 

mental illness is in process. 

4. Co-location of primary care and mental health providers has been in place at 

several facilities over the past few years. Centrally coordinated implementation of 

integrated primary care with mental health co-location/collaborative case 

 

J PRIME (Primary Care in Internal Medicine) is the VA-funded medical residency program designed to produce physicians who 

are committed to both the study and practice of primary care, using evidence-based medicine as the framework for decision 

making and problem analysis.

VA Office of Inspector General 43 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

management is in process and implementation is anticipated over the next year at 

more than 60 sites. 

5. In parallel to utilization in non-VA public and private settings, utilization rates of 

lithium for treatment of bipolar disorder (or anti-depressant augmentation) and 

clozapine for treatment of schizophrenia are low. 

6. An integrated strategy targeting patients with PTSD and substance abuse has been 

piloted at select facilities in VISN 1. 

7. Post-acute detoxification, psychiatric symptoms, and psychological issues in the 

ideal are traditionally addressed in VA and non-VA settings in the context of 

sustained sobriety. VHA offers outpatient mental health treatment for patients 

with on-going substance abuse co-morbidity. Disentanglement of mental illness 

symptoms from substance induced symptoms allows clinicians to interrupt 

perpetuation of physiologic and psychological drives that have been entrained and 

have taken on a life of their own independent of patient history and circumstances, 

to more accurately diagnose and to more appropriately treat underlying illnesses 

and issues. While this approach appears appropriate for and is relatively standard 

for patients with a chronic, longstanding history of substance abuse and/or dual 

diagnosis in non-VA settings, pragmatically, the expectation of sustained sobriety 

prior to admission to specialized inpatient mental health programs may be out of 

step with the needs, reality and expectations of young, returning veterans. 

E. Development of an Electronic Suicide Prevention Database 

National Surveillance System. Ascertaining an accurate rate of suicide among veterans 

is an essential element of a nationwide VHA suicide prevention program. Currently a 

VA national surveillance system and registry is under development and testing but has 

not been fully implemented. 

Â The Serious Mental Illness Treatment Research and Evaluation Center 

(SMITREC) at Ann Arbor, Michigan, has been working on two surveillance 

projects to attempt to accurately determine suicide rates for veterans. Data on 

those who sought health care within VHA in the year 2000 was matched with the 

same data for subsequent years through 2003. A database of patients who did not 

access VHA care in subsequent years was identified. This data was then matched 

to data from CDC’s National Death Index (NDI) to determine which patients no 

longer accessing VHA care had died. The resultant data was then matched to the 

enhanced version of the NDI, which includes cause of death from death 

certificates, to ascertain how many of the deceased veterans had died by suicide. 

Cause of death was classified into three levels of likelihood for suicide. The data 

from these matches is being used to determine a rate inclusive of upper and lower 

bounds. 

VA Office of Inspector General 44 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

Â The National Violent Death Reporting System (NVDRS) is CDC’s effort to 

develop a nationwide, state-based monitoring system for violent deaths. State and 

local agencies use this system to input detailed information from medical 

examiners, coroners, death certificates, and other sources. The NVDRS then pools 

the data with the hope that it can ultimately be used to answer fundamental 

questions about violence related deaths. At present, 17 states participate in the 

system.70 Veteran status is one of several uniform data elements recorded for 

input in the system. Researchers at SMITREC reported cleaning and analyzing 

NVDRS data from Virginia and Oregon in recent months to try to determine an 

overall suicide rate for all veterans in these states. These rates could then be 

compared to the rates determined for VHA utilizers who live in these states. 

Â Once rates are worked out through these two mechanisms, plans are for data to be 

added for subsequent years and rates adjusted. SMITREC researchers hope that 

once rates are determined, predictive models can be used to examine specific 

factors. For example, one factor might be the characteristics of those who suicide 

within 24 hours of receiving care. Researchers hope to evaluate potential temporal 

or regional clusters, or micro-level temporal clusters, such as timing of suicides 

relative to changes in interventions. From the data SMITREC researchers will try 

to ask whether there are previously un-identified at-risk sub-populations or 

correlations with types and intensity of treatment interventions. In addition, 

SMITREC researchers hope to better understand characteristics and determinants 

of the veteran VHA utilizer and non-VHA utilizer sub-populations. 

Conclusion Regarding National Surveillance System. In terms of MHSP initiatives 

related to surveillance, the extent of VHA implementation can be summarized as follows: 

VHA researchers have developed and are in the process of piloting and testing an 

electronic suicide prevention database and surveillance mechanisms. 

F. Education 

First Contact Personnel. Results from the web based survey found that 63 or 57 percent 

of the facility respondents reported that they provide education programs to first contact 

non-clinical personnel. Slightly more than two-thirds of the facilities providing programs 

reported that these programs were mandatory. A little more than half of the facilities 

providing programs reported that these programs included suicide response protocols and 

approximately 70 percent of these facilities reported that programs including response 

protocols were mandatory. 

VA Office of Inspector General 45 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

Overall, approximately 40 percent of all respondent facilities reported providing 

education programs for first contact personnel that were mandatory, approximately onethird of all responding facilities reported inclusion of suicide response protocols, and a 

little less than one-fifth reported that programs inclusive of response protocols were 

mandatory. 

Â In our interviews, we found the VISN 3 MIRECC has established the VISN 3 

Suicide Risk Assessment and Prevention Initiative (SAP) in an effort to “educate 

clinicians, improve recognition of veterans at risk for suicide, improve 

documentation of risk, and enhance communication with mental health and nonmental health clinicians.” As part of the SAP initiative, VISN-wide computerized 

training modules for new staff, mental health staff, and all staff have been 

developed and implemented. A live training module that includes a suicide 

prevention protocol has been piloted for non-clinical staff. In addition, clinicianresearchers have been in the process of developing a script for clerical staff and 

telephone operators specific to VISN 3. 

Â On a central level, VHA implementation of an educational program for first 

contact personnel and non-clinical personnel is in development-pilot stage. One 

consideration discussed has been whether to develop and expand a program within 

VHA (such as the one being developed in VISN 3) or whether to purchase an 

existing proprietary program aimed at the general public. A second consideration 

has been the scope of staff to be included. For example, as is the case with blood 

borne pathogens, would education be required for all personnel; for non-clinical 

VA Office of Inspector General 46 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

personnel in clinical and non-clinical domains such as the cafeteria or canteen; or 

only for non-clinical personnel and first contact personnel who interact with 

veterans within clinical areas of the facility? 

Â The Director of VA Readjustment Counseling Services reported that 100 percent 

of vet center clerical and clinical staff receive suicide prevention 

education/training. In collaboration with researchers at the University of 

Rochester, vet center personnel have participated in suicide prevention regional 

training based on a QPRTM community gatekeeper training model. QPRTM stands 

for “Question, Persuade, and Refer,” an emergency intervention undertaken upon 

the recognition of suicide warning signs in someone known to the QPRTM trained 

person. Gatekeepers are people who regularly come into contact with individuals 

and families in distress. In a community setting, gatekeepers could be 

pharmacists, meter readers, hairdressers, or other groups. QPRTM is designed to 

instill the same response from all who are trained, just like CPR. Because suicidal 

individuals may not tend to self-refer, the model is to train an entire community to 

be aware of symptoms and behaviors and to thereby facilitate earlier intervention 

and referrals for mental health treatment. 

The four principles underlying the theory of a community risk reduction program 

are that: 

(1) Those who most need help in a suicidal crisis are the least likely to ask for 

it; thus, community and family members must recognize and respond 

positively to at-risk loved ones and fellow citizens, and go to them with help 

without requiring that they ask for it first. 

(2) The person most likely to prevent an at-risk individual from dying by 

suicide is someone he or she already knows; thus we must know what to do if 

someone we know becomes suicidal. This can only be accomplished when 

everyone is trained in suicide warning signs and intervention strategies. 

(3) Prior to making a suicide attempt, those in a crisis are likely to send 

warning signs of their distress; thus, learning these warning signs and how to 

take quick, bold action during these windows of opportunity will save lives. 

(4) When we solve the problems people kill themselves to solve, the reasons 

for suicide disappear; thus crisis intervention, problem resolution, enhancement 

of protective factors, and competent and accessible mental health treatment 

will save lives.71 

A gatekeeper training model has been implemented and researched in the U.S. Air Force 

community. In this closed setting, researchers found a 33 percent reduction in suicide 

rate over a 4-year period.72 It was reported to us that researchers at the newly starting 

VA Office of Inspector General 47 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

VA Canandaigua Center of Excellence, whose focus will be suicide prevention from a 

public health approach and dissemination of educational processes, have begun 

demonstration projects in VISN 2 to study the feasibility of adapting and modifying the 

Air Force Suicide Prevention Program for use in VA. 

Health Care Providers. Results from the web based survey indicate that more than 90 

percent of responding facilities indicated that suicide related education programs were 

available at their facility for health care providers. Virtually all of these programs were 

available for physicians, psychologists, nurses, physician assistants, nurse practitioners 

and social workers. At least three-fourths of these programs were available for physical 

therapists, occupational therapists, speech therapists and nursing aides. Six facilities 

reported availability to all employees, nine facilities reported availability to all clinical 

staff, and additional facilities sporadically reported availability to recreation therapists, 

substance abuse counselors, mental health associates and medical assistants. 

Seventeen percent of responding facilities indicated these education programs both 

included information on suicide risks and were also mandatory for all health care 

providers. Twenty-one percent indicated that these programs included information on 

suicide risks and were mandatory for some but not all health care providers and 

62 percent indicated that programs inclusive of information on suicide risks were 

available but not mandatory. One facility indicated that programs including information 

on suicide risks were not available. 

VA Office of Inspector General 48 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

Overall, 99 percent of facilities indicated that ways to address risks were available in 

suicide related education programs. Approximately 15 percent of facilities included ways 

to address suicide risks in suicide related programs and these programs were mandatory 

for all health care providers. At 22 percent of facilities, ways to address suicide risks 

were included and mandatory for some but not all health care providers. At 63 percent of 

facilities, the topic was included in available programs but was not mandatory for health 

care providers. 

Overall, approximately 91 percent of facilities indicated the topic of “best practices” for 

suicide prevention was available in suicide related programs for health care providers. 

Ten percent of these facilities indicated that these programs were mandatory for all health 

care providers. At 16 percent of facilities, these programs were mandatory for some but 

not all health care providers, and at approximately 66 percent of facilities, programs 

inclusive of this topic were available but not mandatory. 

As an extension to MHSP education initiatives, we asked if programs were available to 

educate health care providers on mental health issues in returning OEF/OIF veterans. Of 

the approximately 90 percent, or 109 facilities, that responded in the affirmative, 81 

reported that the content of these programs included information on suicide risk and 11 

facilities reported that these programs were mandatory for all health care providers. The 

National Center for PTSD’s The Iraqi War Clinician Guide (2nd edition available for 

download or in CD form) should be available at facilities. Again, for the 10 percent who 

VA Office of Inspector General 49 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

did not endorse available programs, it is unclear if this reflects lack of availability or lack 

of resource awareness. 

Â As part of the VISN 3 MIRECC’s Suicide Risk Assessment and Prevention 

Initiative, a VISN-wide education program has been implemented throughout 

VISN 3. These programs have included facility-by-facility training sessions, 

comprised of an interview with a control patient, a suicide assessment discussion, 

and hands-on training with a suicide assessment instrument; development and 

implementation of updates for mental health staff on new information on suicide 

risk as it becomes available; and VISN-wide suicide conference with a morning 

VTEL (video-telephone) didactic presentation, followed by afternoon breakout 

sessions at each facility with risk assessment workshops and focus groups on 

suicide risk assessment. Participants reportedly receive training on how to 

respond to patient phone calls. 

We identified the following additional OMH plans or programs aimed at implementing 

training for recognition of at-risk behavior: 

Â In 2000, VHA held its first satellite broadcast on prevention of suicide. The focus 

was on assessment and identification of suicide risk in primary care, mental health, 

and geriatrics. The program was developed with input from the National Institute 

of Mental Health (NIMH) and the University of Rochester, and program videos 

were widely distributed throughout the system. At the time, VHA also developed 

a pocket suicide risk assessment card for distribution to clinicians. In 2001 or 

2002, VHA held a second satellite program on the management of suicide; in 

2004, they had a third satellite program with focus on family and community 

involvement. In 2005, a satellite presentation focused on health promotion and reintegration for war-injured veterans, with an emphasis on clinicians alerting 

patients to signs and potential risks. 

Â In August 2006, material from the War Injury/Suicide Prevention Program (WISP) 

was beta tested. Originally the material was presented in satellite form, but plans 

are for the material to ultimately become web based. In June 2006, the VISN 3 

and VISN 4 MIRECCs ran a regional workshop on evidence based interventions 

for suicide prevention. After editing, there are plans for VHA’s Employee 

VA Office of Inspector General 50 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

Education System (EES) to distribute a DVD to VAMCs that it will produce from 

the June 2006 conference and also to post on the their web site. 

Â In recent months, OMH has been working on development of revisions of the EES 

suicide risk assessment pocket cards. An OMH official reported that there will be 

a revised version for assessment/management in inpatient settings and a second 

version for front line personnel (clinic, emergency department, and so forth) that 

will be available in a PDF word version that staff at VAMCs will be able to 

download and laminate. The revised version for front line personnel inclusive of 

references was reportedly completed in February 2007 and sent to EES. 

Â VISN 4 and VISN 19 MIRECC personnel have conducted in-service training and 

seminars for facilities in these and other VISNs. The VISN 4 MIRECC has been 

hosting yearly suicide prevention conferences. 

Conclusion Regarding Education. In terms of MHSP initiatives related to education, 

the extent of VHA implementation can be summarized as follows: 

1. Fifty-seven percent of facilities provide programs to train first contact non-clinical 

personnel. Only one-fifth of these programs includes suicide response protocols 

and are mandatory. VISN 3 has implemented a training module for all staff and a 

script for clerical staff is under development. VISN 2 sites are piloting QPRTM 

gatekeeper training. Vet center staff receive annual QPRTM gatekeeper training. 

2. Almost all facilities provide education to health care providers on suicide risks, 

ways to address these risks and best practices for suicide prevention. At only a 

small percentage of facilities were these programs mandatory. More than 90 

percent of facilities reported availability of education on mental health issues in 

OEF/OIF veterans. Ten percent of facilities may be unaware of the availability of 

the National Center for PTSD’s Iraq War Clinician Guide. 

3. The VISN 3, 4, and 19 MIRECC staff provide onsite facility training sessions at 

VHA facilities throughout their VISNs. VISN 19 staff provide training sessions at 

facilities throughout VHA. 

Conclusions 

Suicide is an unequivocally tragic and often incomprehensible event. Preventing suicide 

is a complex, multifaceted challenge, to which there is not one “best” practice but several 

promising but not proven approaches and methods. Suicide prevention requires a 

comprehensive plan, integrated strategies, coordinated effort, and steadfast commitment 

to forward progress, since “even the most well-considered plan accomplishes nothing if it 

is not implemented.”73 In the course of this inspection we interviewed clinician-leaders, 

and clinician-researchers dedicated to the prevention of suicide among veterans. Through 

VA Office of Inspector General 51 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

the web based survey we obtained an on-the-ground status report from clinicians who 

serve our Nation’s veterans. Since 2004, significant progress has been made toward 

implementation of the MHSP initiatives for suicide prevention. The progress is ongoing, 

with greater integration and at an accelerated pace. 

However, more work remains to ensure a coordinated effort in achieving system-wide 

implementation. Central to this effort is the ongoing need for greater integration of local, 

network, and national level projects and innovations; a readiness to make difficult 

choices among best available options; and the impetus to translate this readiness into 

widespread and sustained implementation. In the near term, system-wide implementation 

of a set of promising and/or emerging best practices, coupled with their ongoing 

evaluation and modification, would facilitate provision of a single standard of 

preventative care for all veterans seen at VHA facilities. 

A national system-wide suicide prevention plan is intended to provide proactive 

strategies for identifying, screening, assessing, referring, tracking, and treating veterans at 

risk. Although ultimate outcomes cannot be guaranteed, it is anticipated that a 

coordinated, system-wide prevention program could reduce the likelihood of attempted 

and completed suicides. At present, MHSP initiatives for suicide prevention are partially 

implemented. It is therefore incumbent upon VHA to continue moving forward toward 

full deployment of suicide prevention strategies for our Nation’s veterans. 

The following chart depicts the extent of VHA’s MHSP implementation for all 10 

categories, ranging from “No Action” to “System-Wide Implementation.” 

VA Office of Inspector General 52 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

The next table depicts the extent of implementation for each suicide prevention initiative 

unique to the MHSP (it does not include those solely contained in the Surgeon General’s 

National Strategy for Suicide Prevention or the IOM report, Reducing Suicide: A 

National Imperative). 

VA Office of Inspector General 53 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

Recommendations 

Recommendation 1. The Acting Under Secretary for Health should ensure that 

VISN directors ensure that facilities in their VISNs have made arrangements for 24-hour 

crisis and mental health care availability either in person, via a facility-run crisis line, or 

by facility referral to an established, functioning non-VA crisis/suicide hotline staffed by 

trained personnel. In addition, an on-call mental health specialist should be available to 

crisis staff either in person or by phone.

Recommendation 2. The Acting Under Secretary for Health should ensure that 

VISN directors ensure that facility directors ensure that all non-clinical staff who interact 

with veterans receive mandatory training about responding to crisis situations involving 

at-risk veterans; this should include suicide protocols for first contact personnel. 

Recommendation 3. The Acting Under Secretary for Health should ensure that 

VISN directors ensure that facility directors ensure that all health care providers receive 

mandatory education about suicide risks and ways to address these risks. 

VA Office of Inspector General 54 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention 

Recommendation 4. The Acting Under Secretary for Health should ensure that a 

requirement of sustained sobriety should not be a barrier to treatment in specialized 

mental health programs for returning combat veterans. 

Recommendation 5. The Acting Under Secretary for Health should facilitate 

bi-directional information exchange between VA and DoD for patients with mental 

illness coming into VHA health care and/or leaving VHA health care for re-deployment 

to active duty status. 

Recommendation 6. The Acting Under Secretary for Health should establish a 

centralized mechanism to review ongoing suicide prevention strategies, to select among 

available emerging best practices for screening, assessment and treatment, and to 

facilitate system-wide implementation, in order to ensure a single VHA standard of 

suicide prevention excellence. 

VA Office of Inspector General 55 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention

Appendix A 

Survey Questions 

VA Office of Inspector General 

Office of Healthcare Inspections 

Suicide Prevention Questions – Not Including Follow-Up Questions 

Access and Outreach 

(1) At your facility, have efforts been undertaken to promote awareness that suicide is 

a public problem that may be preventable? 

(2) Have strategies been implemented to reduce the stigma associated with being a 

consumer of mental health and/or substance abuse services? 

(3) Has your facility implemented community based suicide prevention programs? 

(4) Have efforts been undertaken to increase access to mental health care and 

substance abuse services? 

(5) In the past 12 months has your facility conducted any suicide or depression 

awareness and/or screening outreach events? 

(6) Have initiatives been undertaken by the Chaplain Service to establish contacts 

with faith-based organizations and community resources to assist with culturally 

competent suicide prevention and other mental health issues? 

Education 

Non-Clinical Personnel

(7) Are programs provided at your facility to educate first contact non-clinical

personnel such as clerks and telephone operators, about crisis situations involving 

veterans at risk for suicide? 

Clinical Personnel

(8) Is your facility affiliated with a medical school? 

(9) Are suicide related education programs available at your facility for health care 

providers (could include web based programs, videoconferences, seminars/colloquia, 

and/or EES programs)? 

(10) Are programs available to educate health care providers on suicide risk factors in 

patients over 65 years old? 

(11) Are programs available at your facility to educate Health Care providers on 

mental health issues in returning OEF/OIF veterans (including web based programs)? 

Primary Care Screening and Referral 

Depression, PTSD, and Substance Abuse - Mental Health Conditions

(12) Are clinical reminders used by primary care providers for screening of OEF/OIF 

veterans for any of the following mental health conditions? 

(13) Does your facility require at least annual screening of veteran’s mental health 

conditions at primary care clinic for the following? 

(14) As of the date of this survey, are mental health clinicians co-located and seeing 

patients at your primary care clinic(s)? 

VA Office of Inspector General 56 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention

(15) When a primary care provider refers a patient with symptoms of moderate 

severity, what is the average length of time before a patient is seen by a mental health 

professional for each of the following conditions: 

(16) Do primary care providers utilize a hierarchical strategy (structured interview 

template or algorithm) to follow positive depression screens with additional inquiries 

about suicidality such as that indicated on the EES Suicide Risk Assessment pocket 

card? 

Suicidality

(17) Do primary care providers utilize tools for recognition of patients with suicidality? 

(18) Do primary care providers utilize tools for screening patients for suicidality? 

(19) Has your facility implemented a system to facilitate referral of veterans with risk 

factors for suicide by primary care providers to specialty mental health care? (e.g., 

policy, guideline, algorithm etc.) 

(20) When a primary care provider detects a patient at risk for suicide, what is the 

average length of time before a patient is seen by a mental health professional? (If 

other, please specify in number of weeks.) 

Mental Health Monitoring and Intervention 

(21) Is mental health care available through your VAMC 24 hours a day? 

(22) Has your facility implemented a strategy for ongoing monitoring of suicidality in 

mental health patients? 

(23) Have intervention strategies been implemented that target periods of increased 

risk for suicide (e.g. first year after initial diagnosis of schizophrenia, end of 

relationship, anniversary of traumatic events such as combat or deaths, etc.) in 

veterans known to have mental health and/or substance abuse disorders? 

(24) Have suicide prevention strategies been implemented to target special emphasis 

groups (e.g. victims of sexual trauma, returning OEF/OIF veterans, bipolar patients 

with mixed states)? 

(25) Is cognitive therapy that is specifically focused on prevention of suicide attempts 

available to patients at your facility? 

(26) Approximate percentage of mental health patients who have been newly 

diagnosed with bipolar disorder type I in the past 24 months who have been prescribed 

lithium treatment by facility mental health providers? 

(27) Approximate percentage of mental health patients with schizophrenia who have 

been prescribed treatment with clozapine over the past 24 months? 

(28) Are specialized substance abuse treatment programs available at your facility? 

(29) Is dialectical behavioral therapy available for patients with borderline personality 

disorder at your facility? 

Tracking Systems 

(30) Has your facility implemented a tracking system for veterans with risk factors for 

suicide? 

(31) At your facility is there a case manager that has been dedicated specifically for 

the care of patients identified by facility providers as high risk for suicide? 

VA Office of Inspector General 57 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention

Appendix B 

Acting Under Secretary for Health Comments 

Department of 

Veterans Affairs Memorandum

Date: April 24, 2007 

From: Acting Under Secretary for Health (10) 

Subject: OIG Draft Report, Implementing VHA’s Mental Health 

Strategic Plan Initiatives for Suicide Prevention, Project 

No. 2006-03706-HI-0007, (WebCIMS 377064) 

To: Assistant Inspector General for Healthcare Inspections (54) 

1. I have reviewed the draft report, and I concur with the 

recommendations therein which will help to ensure a more coordinated 

effort of implementing proactive suicide prevention strategies throughout 

the Veterans Health Administration (VHA). VHA’s goal is to ensure 

continual awareness and prevention of suicide among veterans. 

2. One example of VHA’s ongoing and increasing commitment to 

suicide prevention is the recent designation of Suicide Prevention 

Coordinators in each medical center. These Coordinators will serve to 

facilitate implementation of suicide prevention strategies at the local 

level. Activities will include support for the identification of veterans at 

high risk; coordinating enhanced care when needed; education of 

providers, veterans, families, and members of the community on risk 

factors and warning signs for suicide; and treatment options. 

3. As you know, suicide prevention is among the primary goals of 

VHA’s Mental Health Strategic Plan (MHSP), and since its establishment 

in 2004, significant progress has been made to implement the suicide 

prevention initiatives within the Plan. VHA’s progress in providing 

educational programs on suicide risks and prevention to our health 

providers and non-clinical staff has been ongoing. Prior to the release of 

your report, to further help our system maintain its focus on suicide 

prevention among veterans, I designated March 1, 2007, as Veteran 

Suicide Prevention Awareness Day. This annual event will enhance 

suicide prevention education for clinicians and non-clinical staff 

throughout the VA health care system. Each Vet Center, Veterans 

VA Office of Inspector General 58 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention

Integrated Service Network (VISN), and medical center will hold 

Veterans Suicide Prevention Day annually to conduct suicide prevention 

programs and activities, to include educational presentations that are 

extended during the year through a number of VHA Employee Education 

System (EES) programs. 

4. In addition, VHA is in the process of developing additional awareness 

and training protocols at the local level that involve training of front-line 

patient contact personnel on the concepts of suicide recognition, early 

interventions, and the steps necessary in responding to crisis and 

obtaining assistance for veterans at risk of suicide. Awareness training on 

suicide prevention for clinical personnel is also under development. 

Although these efforts are already outlined with target dates in our 

MHSP, in the interim, we have expedited these initiatives to limit any 

remaining gaps in service delivery involving suicide prevention. 

5. Thank you for the opportunity to review the report. If you have any 

questions, please contact Margaret M. Seleski, Director, Management 

Review Service (10B5) at (202) 565-7638. 

(original signed by:) 

Michael J. Kussman, MD, MS, MACP 

VA Office of Inspector General 59 
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Acting Under Secretary for Health Comments 

to Office of Inspector General’s Report 

The following Acting Under Secretary for Health comments are 

submitted in response to the recommendations in the Office of Inspector 

General’s report: 

OIG Recommendations

We recommend the following: 

Recommendation 1. The Acting Under Secretary for Health should 

ensure that VISN directors ensure that facilities in their VISNs have made 

arrangements for 24-hour crisis and mental health care availability either 

in person, via a facility-run crisis line, or by facility referral to an 

established, functioning non-VA crisis/suicide hotline staffed by trained 

personnel. In addition, an on-call mental health specialist should be 

available to crisis staff either in person or by phone. 

Concur 

VHA, through the Office of Mental Health Services (OMHS) within the 

Office of Patient Care Services, will work with the Office of the Deputy 

Under Secretary for Health for Operations and Management (DUSHOM), 

to ensure 24 hour on-site or on-call coverage by mental health 

professionals in all medical facilities with emergency departments or 24/7 

urgent care centers by June 1, 2007. An implementation plan for all 

remaining faclities will be completed by July 31, 2007, and will include 

standards for determining which faclities should have round the clock and 

onsite coverage, or to include mental health care availability either in 

person, via a facility-maintained crisis line, or facility referral to an 

established, functioning non-VA crisis/suicide hotline. 

OMHS is also currently developing a VA national 24/7 suicide prevention 

hotline that will function as part of a comprehensive program for suicide 

prevention. It is anticipated that this program will be ready for roll-out on 

November 30, 2007, with full national implementation and a follow-up 

assessment of compliance estimated for January 30, 2008. 

In process January 30, 2008 

VA Office of Inspector General 60 
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Recommendation 2. The Acting Under Secretary for Health should 

ensure that VISN directors ensure that facility directors ensure that all 

non-clinical staff who interact with veterans receive mandatory training 

about responding to crisis situations involving at-risk veterans; this should 

include suicide protocols for first contact personnel. 

Concur 

Based on the April 10, 2007, discussion and interpretation of this 

recommendation with Deputy Assistant Inspector General for Healthcare 

Inspections, VHA will work to ensure that each facility has developed 

their own ongoing training, awareness and communication plan that 

includes appropriate procedures/suicide protocols, and community 

resources for all first contact personnel in both clinical and non-clinical 

areas. Each facility will establish a list of those individuals within their 

own areas who would be most likely to interact with veterans at-risk for 

suicide or who may be experiencing some type of crisis, such as, but not 

limited to, telephone operators, registration personnel, volunteers, or 

patient escorts. VHA will establish a work-group comprised of PCS, 

OMHS, the Office of the DUSHOM and EES, not later than April 30, 

2007, to develop a plan to implement the recommended action, 

anticipating that full-roll out will occur no later than October 31, 2007. 

In the interim, an educational offering was presented and made available 

for all VA staff that interacts with patients on March 1, 2007 as part of 

Suicide Prevention Awareness Day. National, system-wide activities will 

be an ongoing process with programs for training for all staff with patient 

contact as part of Suicide Prevention Awareness Day as an annual event. 

Additionally, a number of related EES programs are planned for this year, 

with additional programs projected in subsequent years. The content will 

vary from practical training for non-clinical staff to more conceptuallyoriented training materials for mental health professionals. 

National efforts will be supplemented with local and regional efforts 

implemented as part of the activities of the Suicide Prevention 

Coordinators. These newly created positions were funded on April 1, 

2007 (a position description is attached). A workgroup under the 

leadership of OMHS has been established to develop the educational 

training requirements and needs for this position, and plans to complete 

this work by October 2007. 

In process October 31, 2007 

VA Office of Inspector General 61 
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Recommendation 3. The Acting Under Secretary for Health should 

ensure that VISN directors ensure that facility directors ensure that all 

non-clinical staff who interact with veterans receive mandatory training 

about responding to crisis situations involving at-risk veterans; this should 

include suicide protocols for first contact personnel. 

Concur 

Based on the April 10, 2007, discussion and interpretation of this 

recommendation with Deputy Assistant Inspector General for Healthcare 

Inspections, PCS and OMHS will work with the Office of the DUSHOM 

and EES to develop a mandatory training program, which will include 

different levels of training, based on the professional needs of the 

individual clinician and their clinical responsibilities, to include suicide 

prevention, risk-assessment, protocols and interventions. Development of 

this educational offering was planned as part of the MHSP for the end of 

Fiscal Year 2008, but efforts will be accelerated to be implemented no 

later than October 30, 2007, with full compliance for all facilities by 

January 30, 2008. 

National efforts will be supplemented with local and regional efforts 

implemented as part of the activities of the Suicide Prevention 

Coordinators. 

In process January 30, 2008 

Recommendation 4. The Acting Under Secretary for Health should 

ensure that a requirement of sustained sobriety should not be a barrier to 

treatment in specialized mental health programs for returning combat 

veterans. 

Concur 

The Acting Under Secretary for Health delegated the review of the 

expectation of sustained sobriety prior to admission to specialized 

inpatient PTSD programs to OMHS, within the Office of PCS. 

VA Office of Inspector General 62 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention

The review emphasized the principles that PTSD is often complicated by 

substance use disorders, and that having dual diagnoses should not be a 

barrier to the implementation of treatment. However, it also recognized 

that it may be of value for specialized inpatient PTSD programs to focus 

their efforts on providing specific forms of evidence-based psychological 

treatments, and that substance use or withdrawal may compromise an 

individual’s ability to participate in these interventions. 

To address these principles and emphasize VHA’s commitment to 

providing needed care, OMHS will work with the Office of the 

DUSHOM, to prepare and distribute an information letter from the Acting 

Under Secretary for Health to all VHA facilities through the Veterans 

Integrated Service Networks (VISNs). The letter will confirm VHA’s 

commitment to ensure that inpatient mental health care is available to all 

veterans at the time of need, to those who require it for treatment of 

mental illness, substance use disorders, or dual diagnoses, regardless of 

complicating factors that may have an impact on the overall diagnosis or 

course of treatment. 

In process October 31, 2007 

Recommendation 5. The Acting Under Secretary for Health should 

facilitate bi-directional information exchange between VA and DoD for 

patients with mental illness coming into VHA health care and/or leaving 

VHA health care for re-deployment to active duty status. 

Concur 

There are on-going efforts designed to facilitate the transfer of 

information between DoD and VA to support the clinical care of service 

men and women transitioning between systems, as well as to support the 

health care operations and programs of both Departments. For those with 

serious injuries who have required medical evacuation for acute 

treatment, and subsequent transfer to VA, information sharing about 

mental health conditions as well as other problems is included in the 

Seamless Transition program. For all veterans, DoD is currently sharing 

information derived from Post-Deployment Health Assessments (PDHAs) 

and Post-Deployment Health Reassessments (PDHRAs). VA currently 

shares information on health care provided within its system for veterans 

who have been redeployed with DoD providers on a priority basis. The 

legal authorities for sharing protected health information between DoD 

VA Office of Inspector General 63 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention

and VA for treatment, payment, health care operations and other 

purposes, such as to meet a military mission, are outlined in the DoD/VA 

Memorandum of Understanding for Data Sharing. 

Mechanisms for sharing information about suicide attempts, and possibly, 

other risk factors for suicide could be an important part of VA’s and 

DoD’s efforts at suicide prevention. There is legal authority under 

applicable Federal privacy laws for this information sharing under certain 

conditions; however, the processes on when and how to share information 

in these situations will need to be determined. To ensure that policies 

recognize the importance of this issue, the Acting Under Secretary for 

Health will request that this recommendation and possible future actions 

be addressed by the joint VA/DoD Work Group on Mental Health. 

In process On-going 

Recommendation 6. The Acting Under Secretary for Health should 

establish a centralized mechanism to review ongoing suicide prevention 

strategies, to select among available emerging best practices for 

screening, assessment and treatment, and to facilitate system-wide 

implementation, in order to ensure a single VHA standard of suicide 

prevention excellence. 

Concur 

The Acting Under Secretary for Health will direct PCS/OMHS to 

convene a Suicide Prevention Steering Committee that will consist of: 

additional representation from the Office of Readjustment Counseling 

Service (RCS); National Center for Patient Safety; Office of Public 

Health and Environmental Hazards; Office of Research and 

Development/Health Services Research; Office of Nursing Services; the 

Office of the DUSHOM; the following offices or entities within PCS 

including Primary Care, Geriatrics and Extended Care, Pharmacy Benefits 

Management, Social Work, and field representatives from VISN 19 

Mental Illness Research Education and Clinical Center (MIRECC); the 

Center for Excellence in Mental Health and PTSD at Canandaigua, NY; 

and the Seriously Mental Illness Treatment, Research and Education 

Center (SMITREC). 

The Committee will ensure that on-going suicide prevention strategies 

become integrated broadly into daily VHA operations. Specifically, the 

Committee will guide VHA’s suicide prevention program through onVA Office of Inspector General 64 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention

going review of suicide prevention implementation plans, emerging 

opportunities from advances in research and clinical practice, and both 

epidemiological findings and clinical observations on suicidal behavior 

among veterans. As recommended, its activities will include the selection 

of emerging best practices for screening, assessment, referral, and 

treatment and facilitation of system-wide implementation in order to 

ensure a single VHA standard of suicide prevention excellence. 

This Committee will be convened by June 1, 2007. 

In process June 1, 2007 and on-going 

VA Office of Inspector General 65 
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Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact Michael Shepherd, M.D. 

Washington, DC 

(202) 565-4846 

Acknowledgments Sunil Sen-Gupta 

Marnette Dhooghe 

Rayda Nadal 

Roxanna Osegueda 

Katherine Owens 

VA Office of Inspector General 66 
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Appendix D 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Non-VA Distribution

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction and Veterans Affairs 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction and Veterans Affairs 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

This report is available at http://www.va.gov/oig/publications/reports-list.asp. 

VA Office of Inspector General 67 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention

Appendix E 

Citations 

 

1

 CDC website http://www.cdc.gov/nchs/products/pubs/pubd/hestats/finaldeaths04/finaldeaths04-tables.pdf#2. 2

 CDC WISQARS Leading Cause of Death Reports, 2004, htttp://webappa.cdc.gov/cdi-bin/broker.exe. 3

 American Association of Suicidology website http:www.suicidology.org/associations/1045/files/2004 datapgv1pdf 

drawn from CDC WISQARS website “Fatal Injury Reports” and “Leading Cause of Death Reports.” 4

 Notes from presentation by Ira Katz, MD at Evidence Based Interventions for Suicidal Persons, February 7–9, 

2007, sponsored by VISN 19 MIRECC and American Foundation for Suicide Prevention (AFSP). 

5

 Department of Veterans Affairs, A Comprehensive VHA Strategic Plan for Mental Health Services-Revised, VHA 

Mental Health Strategic Plan Workgroup/Mental Health Strategic Health Care Group, Office of the Assistant 

Deputy Under Secretary for Health, July 9, 2004. 6

, McHugh, Paul R. MD and Slavney, Phillip R. MD, The Perspectives of Psychiatry Johns Hopkins University 

Press, 1998. 

7

 From Suicide Prevention Action Network (SPANUSA) website http:www/spanusa.org, 2007. 8

 Hoyert, D.L., Arias, E., Smith, B.L., Murphy, S.L., & Kochanek, K.D. (2001) Deaths: Final Data for 1999. 

National Vital Statistics Report, 49, 1–113. 9

 CDC WISQARS website http://webappa.cdc.gov/sasweb/ncipc/leadcaus10.html. 10 American Association of Suicidology website http:www.suicidology.org/associations/1045/files/2004. 

datapgv1.pdf drawn from CDC WISQARS website “Fatal Injury Reports” and “Leading Cause of Death Reports.” 

11 National Strategy for Suicide Prevention: Goals and Objectives for Action, U.S. Department of Health and 

Human Services, Public Health Service, Rockville, MD, 2001, from CDC National Center for Health Statistics, 

p. 33. 

12 American Association of Suicidology website http:www.suicidology.org/associations/1045/files/2004. 

datapgv1pdf drawn from CDC WISQARS website “Fatal Injury Reports” and “Leading Cause of Death Reports.” 

13 CDC WISQARS website http://webappa.cdc.gov/cgi-bin/broker.exe. 14 Source: CDC National Center for Health Statistics http://www.cdc.gov/nchs. 

15 Prevalence of and Risk Factors for Lifetime Suicide Attempts in the National Comorbidity Survey, Ronald Kessler 

PhD et al., Archives of General Psychiatry, Volume 56, No. 7, July 1999; p. 617–626. 

16 From testimony of Steven Hyman, MD, National Institute of Mental Health, National Institutes of Health, U.S. 

Department of Health and Human Services, before the Senate Committee on Appropriations, Subcommittee on 

Labor, Health and Human Services, and Education, February 8, 2000. 

17 The Perspectives of Psychiatry, Paul R. McHugh MD and Phillip R. Slavney MD, Johns Hopkins University 

Press, 1998. 

18 Kaplan, H. I., Sadock, B. J., & Kaplan, H. I. Concise textbook of clinical psychiatry. Philadelphia: Lippincott 

Williams & Wilkins, 1996, pp 362364. 

19 From: Department of Veterans Affairs Suicide Prevention Workgroup Final Report (internal document). 

Ann Arbor, Michigan, January 30, 2004. 

20 Psychiatric illness and risk factors for suicide in Denmark, Mortenson, PB, et al., Lancet, January 1, 2000; 

355: 9–12. 

21 From the Joint Commission website http:// Joint Commission.org/NR/rdonlyses. 

22 National Strategy for Suicide Prevention: Goals and Objectives for Action, U.S. Department of Health and 

Human Services, Public Health Service, Rockville, MD, 2001, p.33 from CDC National Center for Health Statistics. 23 From: “Suicide after hospitalization: clinical correlates, quality of care, and usefulness as a quality indicator,” 

Desai, Rani A., Dausey, David J., Rosenheck, Robert A., VA Northeast Program Evaluation Center, presentation 

given at the 2006 Military Suicide Prevention Conference, February 6–9, 2006. 

24 Source: Haas, Gretchen, PhD, VHA VISN 4, MIRECC, Pittsburgh, Pennsylvania. 25 From presentation by Silverman, Morton M., MD, The Opportunities and Challenges of a Public Health 

Approach to Suicide Prevention, presented at Evidence Based Interventions for Suicidal Persons Conference, 

February 7–9, 2007, sponsored by VISN 19 MIRECC and AFSP. 

26 Surgeon General’s Call to Action, U.S. Department of Health and Human Services, 1999. 27 National Strategy for Suicide Prevention: Goals and Objectives for Action, U.S. Department of Health and 

Human Services, Public Health Service, Rockville, MD, 2001, from CDC National Center for Health Statistics, 

pp. 21–22. 

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28 National Strategy for Suicide Prevention: Goals and Objectives for Action, U.S. Department of Health and 

Human Services, Public Health Service, Rockville, MD, 2001, from CDC National Center for Health Statistics, 

pp. 28–32. 

29 National Strategy for Suicide Prevention: Goals and Objectives for Action, U.S. Department of Health and 

Human Services, Public Health Service, Rockville, MD, 2001, from CDC National Center for Health Statistics, 

pp. 34–37. 

30 National Strategy for Suicide Prevention: Goals and Objectives for Action, U.S. Department of Health and 

Human Services, Public Health Service, Rockville, MD, 2001, from CDC National Center for Health Statistics, 

pp. 37–39. 

31 Rose, G., The Strategy of Preventive Medicine, Oxford University Press, 1991. 32 National Strategy for Suicide Prevention: Goals and Objectives for Action, U.S. Department of Health and 

Human Services, Public Health Service, Rockville, MD, 2001, from CDC National Center for Health Statistics, 

pp. 37–40. 

33 National Strategy for Suicide Prevention: Goals and Objectives for Action, U.S. Department of Health and 

Human Services, Public Health Service, Rockville, MD, 2001, from CDC National Center for Health Statistics, 

pp.165–166. 

34 Goldsmith, SK., Pellmar, TC., Kleinman, AM., Bunney, WE., editors, Reducing Suicide: A National Imperative, 

Institute of Medicine of the National Academies, The National Academies Press, Washington, DC, 2002. 

35 From presentation by Silverman, Morton M., MD., The Opportunities and Challenges of a Public Health 

Approach to Suicide Prevention, presented at Evidence Based Interventions for Suicidal Persons Conference, 

February 7–9, 2007, sponsored by VISN 19 MIRECC and AFSP. 

36 Achieving the Promise: Transforming Mental Health Care in America, The President’s New Freedom 

Commission on Mental Health, 2003, pp. 1–6. 

37 From Hogan, Michael F, Ph.D., Chairman, President’s New Freedom Commission on Mental Health, 

accompanying letter to the report, Achieving the Promise: Transforming Mental Health Care in America, The 

President’s New Freedom Commission on Mental Health, 2003. 

38 Achieving the Promise: Transforming Mental Health Care in America, The President’s New Freedom 

Commission on Mental Health, 2003, p. 17-18. 

39 Department of Veterans Affairs, Report to the Secretary, A Comprehensive VHA Strategic Plan for Mental Health 

Services – Revised, Veterans Health Administration, Mental Health Strategic Plan Workgroup, Mental Health 

Strategic Health Care Group, Office of the Assistant Deputy Under Secretary for Health, July 9, 2004, pp. 3–4. 40 Department of Veterans Affairs, Report to the Secretary, A Comprehensive VHA Strategic Plan for Mental Health 

Services – Revised, Veterans Health Administration, Mental Health Strategic Plan Workgroup, Mental Health 

Strategic Health Care Group, Office of the Assistant Deputy Under Secretary for Health, July 9, 2004, pp. 9–10. 41 Department of Veterans Affairs, Report to the Secretary, A Comprehensive VHA Strategic Plan for Mental Health 

Services – Revised, Veterans Health Administration, Mental Health Strategic Plan Workgroup, Mental Health 

Strategic Health Care Group, Office of the Assistant Deputy Under Secretary for Health, July 9, 2004, 

pp. 17, A2, A23. 

42 Department of Veterans Affairs, Report to the Secretary, A Comprehensive VHA Strategic Plan for Mental Health 

Services– Revised, Veterans Health Administration, Mental Health Strategic Plan Workgroup, Mental Health 

Strategic Health Care Group, Office of the Assistant Deputy Under Secretary for Health, July 9, 2004, p.17. 43 U.S. Preventive Services Task Force (USPSTF), Screening for Suicide Risk: Recommendation and Rationale, 

May 2004, Agency for Healthcare Research and Quality, Rockville, MD. 

http://ahrq.gov/clinic/3rduspstf/suicide/suiciderr.htm. 

44 From presentation by Jobes, David A, PhD, ABPP, Professor of Psychology, The Catholic University of America, 

Washington , DC, Suicide Event Reporting and Rate Standardization, at the 2006 Military Suicide Prevention 

Conference, February 6–9, 2006. 

45 Mills, Peter D, PhD, MS, et al., Actions and Implementation Strategies To Reduce Suicidal Events in the Veterans 

Health Administration, Joint Commission Journal on Quality and Patient Safety, Volume 32, Number 3, March 

2006. 

46 From presentation by Haas, Ann PhD, Suicide Research at the American Foundation for Suicide Prevention, at 

the Evidence Based Interventions for Suicidal Persons Conference, February 7–9, 2007, sponsored by VISN 19 

MIRECC and AFSP. 

VA Office of Inspector General 69 
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47 From presentation by Silverman, Morton M., MD., The Opportunities and Challenges of a Public Health 

Approach to Suicide Prevention, presented at Evidence Based Interventions for Suicidal Persons Conference, 

February 7–9, 2007, sponsored by VISN 19 MIRECC and AFSP. 

48 From presentation by Silverman, Morton M., MD., The Opportunities and Challenges of a Public Health 

Approach to Suicide Prevention, slide adapted from the Third National Injury Control Conference (1992), presented 

at Evidence Based Interventions for Suicidal Persons Conference, February 7–9, 2007, sponsored by VISN 19 

MIRECC and AFSP. 

49 Violence – A Global Public Health Problem, World Health Organization, 2002, p.16. 50 From the Joint Commission website. http://Joint Commission.org/NR/rdonlyses. 

51 U.S. Preventive Services Task Force, Screening for Depression: Recommendations and Rationale, Agency for 

Healthcare Research and Quality, Rockville, MD, May 2002. 

52 Jollant, Fabrice, MS, Bellivier, MD, PhD, et all, Impaired Decision Making in Suicide Attempters, American 

Journal of Psychiatry, February 2005; 162, pp. 304–310. 

53 Mann, John J, MD, Neurobiological Aspects of Suicide, New York State Office of Mental Health, 

http://www.omh.state.ny.us/omhweb/savinglives/Volume 2/neurobiological.html. 54 Oquendo, Maria A, MD, Mann, John J, MD., Identifying and Managing Suicide Risk in Bipolar Patients, The 

Journal of Clinical Psychiatry, 2001, volume 62 supplement 25, pp.31–34. 

55 From Presentation and handout by Najavits, Lisa PhD, at Evidence Based Interventions for Suicidal Persons 

Conference sponsored by VISN 19 MIRECC and AFSP, February 7–9, 2007. 

56 From Presentation by Brown, Greg PhD, and Wenzel, Amy PhD, at Evidence Based Interventions for Suicidal 

Persons Conference sponsored by VISN 19 MIRECC and AFSP, February 7–9, 2007. 

57 Brown, Greg PhD, et al., Cognitive Therapy for the Prevention of Suicide Attempts: A Randomized Controlled 

Trial, Journal of the American Medical Association, Volume 294 No.5, August 3, 2005, pp.563–570. 

58 From presentation by Jobes, David A, PhD, ABPP, at Evidence Based Interventions for Suicidal Persons 

Conference sponsored by VISN 19 MIRECC and AFSP, February 7–9, 2007. 

59 Jobes, David A, PhD., Managing Suicidal Risk: A Collaborative Approach, Guilford Publications, New York, 

New York, 2006. 

60 Oldham, John M, MD., Borderline Personality Disorder and Suicidality, The American Journal of Psychiatry, 

January 2006, 163(1):20. 

61 From Reynolds, Sarah, PhD, and Proietti, Joseph, MS, Western Psychiatric Institute and Clinic, Dialectical 

Behavior Therapy, One-Day Workshop, Highland Drive VA Hospital, September 26, 2003. 62 Valenstein, Marcia, MD, et al., What Happened to Lithium? Antidepressant Augmentation in Clinical Settings, 

The American Journal of Psychiatry, July 2006, Volume 163, pp. 1219–1225. 

63 Baldessarini RJ, Tondo L, Hennen J, Lithium Treatment and Suicide Risk in Major Affective Disorders: Update 

and New Findings, Journal of Clinical Psychiatry, 2003 (supplement 5), 64:44–52. 64 Meltzer, Herbert Y, MD, Okayli, G, MD., Reduction of suicidality during clozapine treatment of neurolepticresistant schizophrenia: impact on risk-benefit assessment, The American Journal of Psychiatry, 1995, 

152: 183–190. 

65 Bourgeois, Marc MD, et al., Awareness of Disorder and Suicide Risk in the Treatment of Schizophrenia: Results 

of the International Suicide Prevention Trial, The American Journal of Psychiatry, August 2004, 161: 1494–1496. 66 From presentation by Levine, Bruce MD, Psychopharmacological Interventions for Suicidal Individuals, at 

Evidence Based Interventions for Suicidal Persons Conference sponsored by VISN 19 MIRECC and AFSP, 

February 7–9, 2007. 

67 From Katz, Ira R. MD at the at the Evidence Based Interventions for Suicidal Persons Conference, sponsored by 

VISN 19 MIRECC and AFSP, February 7–9, 2007. 

68 Alexopoulos, George S, MD, et al., Remission in Depressed Geriatric Primary Care Patients: A Report from the 

PROSPECT Study, American Journal of Psychiatry, April 2005, Volume 162 pp. 718–724,. 69 Mills, Peter D, PhD, DeRosier, Joseph PE, Ballot, Bryan MD, and Shepherd, Michael MD, Inpatient Suicide and 

Para-Suicide in Veterans Affairs, 2007 (unpublished draft). 70 From CDC, National Center for Injury Prevention, National Violent Death Reporting System website, 

http://www.cdc.gov.ncip/profiles/nvdrs/facts.htm. 

71 From QPRTM Institute website: http://www.qprinstitute.com/ 

72 Knox, Kerry L. PhD, et al., Risk of suicide and related adverse outcomes after exposure to a suicide prevention 

programme in the US Air Force: cohort study, British Medical Journal, December 13, 2003. 

VA Office of Inspector General 70 
Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention

73 From a letter from the Surgeon General, U.S. Department of Health and Human Services, as preface to the 

Surgeon General’s Call to Action, 1999. 

VA Office of Inspector General 71