Health Care for Veterans: Suicide Prevention
Released: 2016-02-23T00:00:00

Summary:
This report focuses on suicide prevention activities of the Veterans Health Administration (VHA) within the Department of Veterans Affairs (VA). The VHA's approach to suicide prevention is based on a public health framework, which has three major components: (1) surveillance, (2) risk and protective factors, and (3) interventions.
Surveillance, or systematic collection of data on completed (i.e., fatal) suicides, is essential to define the scope of the problem (i.e., the suicide rate among veterans), identify characteristics associated with higher or lower risk of suicide, and track changes in the suicide rate. No nationwide surveillance system exists for suicide among all veterans. Information about deaths (including suicides) is collected in death certificates by state, territorial, and local governments. Death certificate data are aggregated into the National Death Index, which can be combined with data about who is a veteran to identify veteran suicides. The VHA collects detailed information about suicides among veterans that are known to VHA facilities; however, the majority of veterans are not enrolled in VHA health care, so other sources of information (e.g., Department of Defense data) are necessary to identify veterans.
Information collected in surveillance is used to identify suicide risk factors (i.e., characteristics associated with higher rates of suicide) and protective factors (i.e., characteristics associated with lower rates of suicide). This is essential in order to design interventions that reduce risk factors and/or increase protective factors, thus lowering overall risk of suicide. Risk factors are also helpful in identifying at-risk groups or individuals so that interventions can be delivered to the people who need them most. Within the VHA, this research is supported by the Office of Research and Development; a Center of Excellence in suicide prevention; and a Mental Illness Research, Education, and Clinical Center on suicide prevention.
The intervention cycle includes three stages: (1) design and test interventions, (2) implement interventions, and (3) evaluate interventions. The research components mentioned above have roles in small-scale pilot testing and large-scale evaluations of interventions. VHA suicide prevention interventions include easy access to care, screening and treatment, suicide prevention coordinators, suicide hotline, education and outreach, and limited access to lethal means.
The VHA has received both praise and criticism for its suicide prevention efforts and mental health services more generally. A 2010 progress report on the National Strategy for Suicide Prevention describes the VHA as "one of the most vibrant forces in the U.S. suicide prevention movement, implementing multiple levels of innovation and state of the art interventions, backed up by a robust evaluation and research capacity." In contrast, some have testified before Congress that VHA's suicide prevention efforts have inadequacies, such as barriers to accessing care and lack of evidence-based treatments for those who do access care. A 2011 evaluation of VHA mental health services captures both sides of the argument, finding that VHA mental health care is generally at least as good as that of other health care systems, but that it "often does not meet implicit VA expectations." An independent evaluation of VA mental health services is underway.
Potential issues for Congress and related recommendations by outside organizations fall into three categories: improving the timeliness and accuracy of surveillance data, building the evidence base, and increasing access to evidence-based mental health care. Public laws addressing suicide prevention among veterans are described in the Appendix.

paragraphs: C ongress has attempted to address the problem of suicide among veterans through legislation and oversight hearings, both on prevention of veteran suicide specifically and on veteran mental health more broadly. A task as challenging as preventing suicide requires collaboration among federal agencies, state and local governments, other organizations, communities, and individuals. This report, however, focuses on activities of the Veterans Health Administration (VHA) within the Department of Veterans Affairs (VA). The VHA's approach to suicide prevention is based in part on the National Strategy for Suicide Prevention, which involves multiple federal departments, including the VA, Defense (DOD), and Education (ED), as well as several agencies within Health and Human Services (HHS). While this CRS report focuses on suicide prevention efforts of the VHA, activities of other entities are discussed as they relate to VHA activities. 
This CRS report begins with a brief overview of the public health framework for suicide prevention, which forms the basis for both the National Strategy for Suicide Prevention and the VHA's approach to suicide prevention. The three subsequent parts of the report correspond to the three major components of the public health framework: (1) suicide surveillance, (2) suicide risk factors and protective factors, and (3) suicide prevention interventions. The final section addresses potential issues for Congress, and the Appendix summarizes provisions of public laws addressing suicide prevention among veterans.
subsections: section_title: A Public Health Framework for Suicide Prevention
paragraphs: Prevention of suicide can be approached in two ways, which are not mutually exclusive. The public health approach intervenes with populations (e.g., distributing educational materials about mental illness and mental health services), whereas the clinical approach intervenes with individuals (e.g., prescribing antidepressant medication to a person diagnosed with depression). The individual focus of the clinical approach limits its reach to those who access the health care system; clinical interventions are necessary but not sufficient. The population-based public health approach is considered essential to address the broader problem of suicide among all veterans, including those who may not currently be in contact with the health care system. 
Both the National Strategy for Suicide Prevention and the VHA's approach to suicide prevention are based on a public health framework. As illustrated in Figure 1 , the framework has three major components: (1) surveillance, (2) risk and protective factors, and (3) prevention interventions. Suicide surveillance involves collecting data on completed (i.e., fatal) suicides in order to define the scope of the problem. Data collected in surveillance can be used to identify risk factors (i.e., characteristics associated with higher suicide risk) and protective factors (i.e., characteristics associated with lower suicide risk). Suicide prevention interventions aim to reduce risk factors and/or enhance protective factors that have been identified; interventions may target high-risk groups or individuals, identified based on known risk factors. 
section_title: VHA Suicide Surveillance
paragraphs: No nationwide surveillance system exists for suicide among all veterans. Surveillance, or systematic collection of data on completed (i.e., fatal) suicides, is essential to define the scope of the problem (i.e., the suicide rate among veterans), to identify characteristics associated with higher or lower risk of suicide, and to track changes in the suicide rate and evaluate suicide prevention interventions. In order to evaluate interventions, suicide surveillance must measure the same thing, in the same way, repeatedly over time. In the case of veteran suicide, surveillance requires identifying both who is a veteran and who has died by suicide. 
The VHA collects detailed information about suicides (and suicide attempts) among veterans that are known to VHA facilities through the Behavioral Health Autopsy Program (BHAP), which will eventually collect information in four phases. The VHA has already implemented the two phases: standardized chart reviews and interviews with family members. The third and fourth phases involve interviewing the last clinician to see the veteran and locating public records that might indicate stressors (e.g., bankruptcy or divorce). A Government Accountability Office (GAO) evaluation found that some BHAP reports were not submitted, some included inaccurate information, and some were incomplete. VHA facilities had interpreted BHAP instructions differently, and no officials were reviewing BHAP reports for accuracy or completeness. 
Resolving the problems the GAO identified with BHAP would result in better information about suicides among veterans that are known to VHA facilities; however, information collected solely by the VHA would still exclude suicides among other veterans (i.e., those who are not known to the VHA). Of more than 21 million veterans estimated to live in the United States, fewer than 10 million are enrolled to receive health care from the VHA. The VA also has records of veterans who receive other benefits (e.g., home loans), regardless of whether they are enrolled in VHA health care, but does not have records of all veterans. The VA is working with the DOD to identify suicides among all veterans, including those who do not interact with the VA. 
Information about deaths—including whether a death resulted from intentional self-harm (i.e., suicide)—is collected in death certificates by state, territorial, and local governments. The resulting data may not be comparable across jurisdictions. The Centers for Disease Control and Prevention (CDC) aggregates death certificate data into the National Death Index (NDI), which can then be combined with data about who is a veteran. The lag between a suicide event and identification of the decedent as a veteran may be years; this delays the availability of crucial information. Timely reporting of death certificates was identified as a core issue in a 2010 progress report on the National Strategy for Suicide Prevention.
section_title: VHA Research into Risk and Protective Factors
paragraphs: The VHA conducts veteran-specific research that builds on research among the general population to identify characteristics associated with higher rates of suicide (i.e., risk factors) and lower rates of suicide (i.e., protective factors). Identifying risk and protective factors is essential in order to design effective interventions aimed at lowering overall risk of suicide by reducing risk factors and/or increasing protective factors. Knowing what the risk factors are also helps in identifying at-risk groups or individuals so that interventions can be delivered to the people who need them most. Table 1 provides examples of risk and protective factors among the general population. 
Within HHS, both the CDC and the National Institute of Mental Health (NIMH) disseminate research on suicide risk and protective factors within the general population. Also, the Substance Abuse and Mental Health Services Administration (SAMHSA) collects data on suicide attempts and related behavior. It should be noted that risk factors for attempted suicide may differ from risk factors for completed suicide; for example, women have a higher rate of attempted suicide, but men have a higher rate of completed suicide. Despite a large number of risk and protective factors identified by researchers, it is not yet possible to predict who will attempt or complete suicide. The inability to identify individuals most in need of interventions is one of the reasons a public health approach—with a focus on population-level interventions—is necessary for effective suicide prevention. 
Veteran-specific research on suicide risk and protective factors is necessary because the veteran population differs from the non-veteran population on a variety of characteristics (e.g., gender distribution), some of which may also be associated with suicide risk. Research has explored whether combat exposure is associated with risk of suicide (with mixed results). Veterans who are enrolled with the VHA may differ from non-enrolled veterans, as well. 
Within the VHA, research on suicide risk and protective factors is supported by three research components: the Office of Research and Development (ORD), a Center of Excellence (COE) in suicide prevention, and a Mental Illness Research, Education, and Clinical Center (MIRECC) on suicide prevention. Administratively, both the COE and the MIRECC (as well as other centers) fall under the Mental Health Strategic Healthcare Group, which is separate from ORD. 
subsections: section_title: VHA Office of Research and Development (ORD)
paragraphs: In general, the ORD funds intramural research (including mental health research) by individual VHA investigators. The ORD's Health Services Research and Development Service supports research into suicide risk factors and protective factors. For example, the VHA conducted a study of suicide risk among veterans with depression (a known risk factor in the general population, as well as among veterans). Another study examined characteristics associated with suicide risk among patients seen in VHA primary care, to help identify factors that primary care providers may be able to use to detect suicide risk. These studies, and others like them, can help the VHA identify veterans at high risk of suicide, so that interventions can be targeted to them. 
section_title: Center of Excellence (COE)
paragraphs: The COE at Canandaigua, NY, conducts research on risk and protective factors, in addition to other suicide prevention activities. Established in August 2007 at the direction of Congress, the COE has the mission of developing and studying evidence-based public health approaches to prevention of veteran suicide, with the goal of reducing morbidity and mortality associated with suicide in the veteran population. In pursuit of its mission, the Epidemiology and Interventions Research Core within the COE collects and analyzes data on suicide risk and protective factors (as well as other topics) among both veterans who use VHA services and those who do not.
section_title: Mental Illness Research, Education, and Clinical Center (MIRECC)
paragraphs: The MIRECCs, also established at the direction of Congress, conduct research on a range of mental health-related topics, including suicide risk factors and protective factors. Specifically, the MIRECC of the VA Rocky Mountain Network pursues the goal of reducing suicidality in the veteran population, by conducting research on potential contributions of cognitive and neurobiological factors, among other activities. For example, one study assesses the relationship (if any) between suicidal ideation and thinking under stress. Other MIRECCs may also conduct research related to suicide, in the course of pursuing their other goals. 
section_title: Selected VHA Suicide Prevention Interventions
paragraphs: Suicide prevention interventions aim to reduce risk factors and/or enhance protective factors, thereby lowering the risk of suicide. They may address entire populations (e.g., all veterans), at-risk subgroups (e.g., veterans diagnosed with a mental disorder), or high-risk individuals (e.g., veterans with recent suicide attempts). 
Interventions are refined in a three-stage cycle. The first stage is to develop and pilot test interventions on a small scale to ensure that they are safe, ethical, feasible, efficacious (i.e., they work under ideal conditions), and effective (i.e., they work under real-world conditions). If interventions are successful in the first stage, the second stage is to implement them on a larger scale. The third stage is to evaluate interventions that have been implemented on a larger scale, to verify their effectiveness and determine for whom they are most effective. The three stages can then be repeated to refine interventions, either to improve their effectiveness or to adjust them for use with a different population (e.g., applying an intervention developed for male veterans to a population of female veterans). 
Within the VHA, the same research components that study risk and protective factors research evaluate interventions: ORD, COE, and MIRECC. Both small-scale testing and large-scale evaluation are integral to suicide prevention interventions; however, rigorous research on effectiveness is difficult and lacking for most interventions, both within and outside the VHA. 
subsections: section_title: Easy Access to Care
paragraphs: Easy access to care is a protective factor against suicide, and recent laws have included provisions aimed at increasing veterans' access to VHA-provided or VHA-funded care (not limited to mental health care). The Veterans Access, Choice, and Accountability Act of 2014 ( P.L. 113-146 , as amended) aims to increase access to care by requiring the VHA to authorize reimbursement for non-VHA care under certain circumstances. More recently, the Clay Hunt Suicide Prevention for American Veterans Act ( P.L. 114-2 ) included a one-year extension of the existing five-year post-discharge period of enhanced enrollment in VHA health care for certain veterans. The Congressional Budget Office (CBO) estimates that this provision will result in the enrollment of about 4,600 veterans, including 1,400 who would not otherwise be able to enroll. 
VHA policy requires that emergency mental health care be available 24 hours per day through emergency rooms at VA facilities or local, non-VA hospitals; that new patients referred for mental health services receive an initial assessment within 24 hours and a full evaluation appointment within 14 days; and that follow-up appointments for established patients be scheduled within 30 days. The extent to which these policies are implemented in practice has been questioned in congressional testimony, news media, and survey responses from both providers and patients. 
Other efforts to increase access to mental health care focus on known barriers such as lack of understanding or awareness of mental health care, stigma associated with mental illness, concerns about VHA care, and challenges in scheduling appointments. The VHA provides information to help increase awareness of mental health care services, reduce the stigma associated with seeking care, and correct misconceptions about VHA care. Some mental health and substance use evaluation and treatment services have been integrated into other treatment settings, which both increases the convenience and reduces the stigma associated with seeking care. The VHA is required to conduct a three-year pilot program using outreach programs and peer support networks to assist recently discharged veterans in accessing VHA mental health services.
section_title: Screening, Assessment, and Follow-Up
paragraphs: Some types of screening are supported by evidence that they reduce the likelihood of suicide. The U.S. Preventive Services Task Force (USPSTF), which makes evidence-based recommendations about screenings and other clinical preventive services, recommends depression screening in primary care settings "when appropriate systems are in place to ensure adequate diagnosis, treatment, and follow-up." That is, the recommendation to use screenings is contingent upon the availability of further evaluation, treatment, and follow-up care. Without such systems in place, screening would serve little purpose. 
VHA policy requires screening for a variety of risk factors, including but not limited to depression, posttraumatic stress disorder (PTSD), and alcohol abuse. Those who screen positive are evaluated further and offered treatment if found to have a mental health problem. Positive screens for PTSD or depression, in particular, are followed by a suicide risk assessment.
section_title: Treatment of Mental Illness
paragraphs: For individuals identified as having mental illness, clinical interventions may be indicated regardless of specific risk of suicide. Clinical interventions may include pharmacotherapy, psychotherapy, or both. The VA and the DOD have jointly developed clinical practice guidelines for treatment of some conditions, to help clinicians select treatments that research has shown to be effective (i.e., evidence-based treatments). 
A 2011 evaluation of VHA mental health care finds that treatment in the VHA is generally better than in other systems on a variety of measures, but still has room for improvement. In particular, the evaluation finds that evidence-based treatments, while widely available, are not usually provided. Researchers based this finding on a review of medical records, which showed that prescriptions for medication were often not filled for as long as recommended and that psychotherapy, as documented, was often not delivered according to evidence-based guidelines. Additionally, the evaluation found that assessment of veterans' symptoms is lacking, both at the beginning of treatment and during treatment (to track progress). Another third-party evaluation of the VHA's mental health care system is underway, to be completed by the end of FY2017. Third-party evaluations of VHA mental health care and suicide prevention programs are now required annually, with the first to be completed by the end of FY2018.
section_title: Suicide Prevention Coordinators
paragraphs: Per department policy, every VA Medical Center has at least one suicide prevention coordinator, whose responsibilities include (among other things) tracking patients who have been identified as at high risk for suicide. The VHA's computerized patient record system enables clinicians to flag high-risk patients, and policy requires that safety plans be developed for them. A safety plan is a written document developed jointly by a patient and a clinician that identifies strategies for coping in a crisis (e.g., recognizing warning signs and contacting family members, friends, or mental health providers). Outside the VHA, the use of suicide prevention coordinators has not been widely adopted, although some components of the program (e.g., safety plans) are widely used. The suicide prevention coordinator program has been identified as a practice worth emulating by a DOD task force on suicide prevention.
section_title: Suicide Hotline
paragraphs: Suicide hotlines are telephone numbers individuals can call for help in crisis situations (e.g., at the moment they are considering suicide). Hotlines are generally toll-free and available around the clock. The Veterans Crisis Line is a joint effort of the VHA and SAMHSA. The main line (1-800-273-8255) is the National Suicide Prevention Lifeline, operated by SAMHSA. Veterans (or others calling with concerns about veterans) may select option 1 to be directed to the VHA's Veterans Crisis Line, answered by staff at the COE in Canandaigua, NY. Callers may remain anonymous or disclose their identities in order to allow the COE staff to access their VA medical records during the call. The Veterans Crisis Line is supplemented by an online chat service ( http://www.VeteransCrisisLine.net/chat ) and support via text messaging (text 838255). The Veterans Crisis Line has answered nearly 2 million calls since it began in 2007, has engaged in more than 250,000 chats since it added the chat service in 2009, and has responded to more than 44,000 texts since it added the text-messaging service in 2011.
The evidence base for suicide hotlines is not sufficient to determine their effectiveness in reducing suicide rates, due to the difficulties inherent in conducting such evaluations. The confidentiality of suicide hotlines renders follow-up with each individual caller impossible (except in cases when a caller voluntarily discloses his or her identity). Moreover, national hotlines, such as those operated by SAMHSA and the VHA, serve a large geographic area. A range of other interventions may be in place in localities within the hotline's reach, such that any change in the suicide rate may not be attributable to the hotline. 
In February 2016, the VA Office of Inspector General released a report about an inspection conducted in response to complaints about the Veterans Crisis Line. Among the complaints substantiated by the VA Office of Inspector General, some calls that were routed to backup crisis centers were answered by voicemail. The routing of calls from SAMHSA's National Suicide Prevention Lifeline to VA's Veterans Crisis Line and from VA's Veterans Crisis Line to backup crisis centers is handled by a contractor, Link2Health Solutions, Inc. The Executive Director of VHA's Office of Mental Health Services and Operations concurred with all seven recommendations made by the VA Office of Inspector General. 
section_title: Education and Awareness
paragraphs: The VHA offers suicide prevention education and outreach to staff, patients, and surrounding communities. All VHA health care providers are required to complete web-based training on suicide risk and intervention and to pass a post-test. VHA Suicide Prevention Coordinators are required to conduct outreach activities in their local communities. The VHA has co-sponsored (with the Department of Defense) conferences on suicide prevention to educate clinicians and has sponsored Suicide Prevention Days to raise awareness. 
section_title: Limited Access to Lethal Means
paragraphs: As of 2014, the three most common means of completing suicide among the general population are firearms (50%), suffocation (27%), and poisoning (16%). Evidence supports restricting access to lethal means (e.g., firearms, gas, drugs) as a way to reduce suicide rates. In some cases, means restriction may delay a suicide attempt long enough that the impulse passes, which may require only several minutes. In other cases, an individual may attempt suicide using a different method that is less lethal (e.g., drugs rather than firearms). The VHA has a gun safety program (as both a child safety initiative and a suicide prevention initiative), which includes distribution of free gun locks and dissemination of gun safety information. The VHA also conducts research on blister packaging medications as a potential way to reduce the incidence of medication overdoses. 
section_title: Potential Issues for Congress
paragraphs: The VHA has received both praise and criticism for its suicide prevention efforts and mental health services more generally. A 2010 progress report on an earlier version (2001) of the National Strategy for Suicide Prevention praises VHA's suicide prevention practices and recommends disseminating them to the rest of the health care system, describing the VHA as "one of the most vibrant forces in the U.S. suicide prevention movement, implementing multiple levels of innovation and state of the art interventions, backed up by a robust evaluation and research capacity." In contrast, some congressional testimony has criticized VHA's suicide prevention efforts for inadequacies, such as barriers to accessing care and lack of evidence-based treatments for those who do access care. A 2011 evaluation of VHA mental health services captures both sides of the argument, finding that VHA mental health care is generally at least as good as that of other health care systems, but that it "often does not meet implicit VA expectations." 
Potential issues for Congress and related recommendations by outside organizations fall into three categories: improving the timeliness and accuracy of surveillance data, building the evidence base, and increasing access to evidence-based mental health care. 
subsections: section_title: Improving the Timeliness and Accuracy of Surveillance Data
paragraphs: Challenges in suicide surveillance include timeliness of data, consistent classification of deaths as suicides, and accuracy of information. Addressing these challenges requires the involvement of entities other than VHA. 
Recommendations related to the timeliness of suicide surveillance data include ensuring that the CDC's ability to compile national death data expeditiously is not limited by a lack of resources; coordinating the annual analysis of veteran suicide data among VA, DOD, and HHS; and establishing "reasonable time requirements for states to provide death data to the CDC." It should be noted that states, territories, and cities voluntarily share vital statistics with the CDC, so offering incentives for timely data might be more feasible than imposing requirements.
It is widely believed that inconsistent reporting of suicides across jurisdictions, as well as underreporting of suicides in general, limits the effectiveness of surveillance efforts. Classification of a death as a suicide requires a determination that the death is both self-inflicted and intentional. Determining the decedent's intent is difficult, and coroners or medical examiners may feel pressure not to classify a death as suicide, due to the stigma associated with suicide. Suicides may be underreported when the manner of death is misclassified as "undetermined" or "accidental" (e.g., poisonings or single-vehicle crashes). Additionally, each jurisdiction (state, territory, or city) has its own requirements for investigating deaths, leading to variability across jurisdictions. 
The GAO recommends that the VA implement processes to improve the completeness, accuracy, and consistency of data reported through the VHA's Behavioral Health Autopsy Program (BHAP) system. Beyond that, the VA must rely on outside data sources (e.g., the DOD) to identify decedents as veterans if they are not enrolled with the agency. 
section_title: Building the Evidence Base
paragraphs: Developing an adequate evidence base is necessary both to identify risk and protective factors and to develop and disseminate effective interventions. Recommendations include increased information sharing, collaboration, and dialogue across areas of public health, among government agencies, and between congressional committees. 
Suicide prevention tends to operate in its own silo, even though suicide has some of the same risk and protective factors as other public health problems. Increased collaboration and dialogue between suicide prevention and other areas of public health "will help prevent the field from endlessly recreating wheels and spreading the limited funds too broadly to make a sustainable difference." 
If agencies (federal, state, or local) engage in ongoing collaboration and dialogue, sharing evaluations of existing interventions and research into new interventions, they may prevent unnecessary duplication of effort and help build the evidence base more quickly. (Note that replication of studies is an integral part of the research process, so a distinction may be made between appropriate and unnecessary duplication of effort.) Specific recommendations include sharing research findings among the VA, DOD, and HHS and fast-tracking all phases of the intervention cycle (designing and pilot testing interventions, implementing interventions, and evaluating interventions), as well as the dissemination of the knowledge gained in each phase. 
Some have also recommended that the House and Senate Committees on Veterans' Affairs initiate discussions with the House and Senate Armed Services Committees to develop provisions addressing veteran suicide in the National Defense Authorization Act. 
section_title: Increasing Access to High-Quality Mental Health Care
paragraphs: Providing timely access to high-quality mental health care has been a challenge for the VHA. The Veterans Access, Choice, and Accountability Act of 2014 ( P.L. 113-146 , as amended) aims to increase access for veterans seeking VHA care (not limited to mental health care). Among other things, the act establishes the Veterans Choice Program, which requires the VHA to authorize reimbursement for non-VHA care under specified conditions. One such condition occurs when a qualified veteran is unable to schedule an appointment within the VHA's wait-time goals. In accordance with the act, the VHA has established a wait-time goal "to furnish care within 30 days of either the date that an appointment is deemed clinically appropriate by a VA health care provider, or if no such clinical determination has been made, the date a veteran prefers to be seen." 
Access to VHA mental health care is determined in part by the availability of providers. Pursuant to P.L. 113-146 , the VA Office of Inspector General (OIG) identified five occupations with the largest shortages: medical officer (i.e., physician), nurse, physician assistant, physical therapist, and psychologist. The OIG report does not specify physician specialties (e.g., psychiatrists). A shortage of psychologists might be mitigated by hiring other providers with similar scopes of practice (i.e., social workers, mental health counselors, and marriage and family therapists); however, the VHA may also have shortages among those occupations as the OIG report lists only the top five. The VHA has both long-standing and recently established mechanisms available to improve recruitment and retention of providers (e.g., educational debt repayment programs). 
The Clay Hunt Suicide Prevention for American Veterans Act ( P.L. 114-2 ) aims to expand access to care by extending the existing period of enhanced enrollment, requiring a pilot program to conduct community outreach, requiring a pilot program to repay the education loans of qualified psychiatrists, and authorizing collaboration with nonprofit mental health organizations.
When veterans gain access to care—within or outside the VHA—they may not always receive high-quality care. While the VHA has made progress in disseminating knowledge about evidence-based treatment (e.g., through clinical practice guidelines developed jointly with DOD), that does not guarantee implementation of such treatments. A 2011 evaluation of VHA mental health care finds room for improvement in the use of evidence-based treatments. Another third-party evaluation of the VHA's mental health care system is underway (to be completed by the end of FY2017), and independent evaluations of VHA mental health care and suicide prevention programs are required annually (with the first to be completed by the end of FY2018). 
A 2014 report by the RAND Corporation indicates that only 13% of evaluated mental health providers (not limited to VHA providers) met study criteria for readiness to provide veteran-friendly, high-quality care. Providers working within the VHA or a military setting were more likely than others to meet the criteria, which may raise questions for some about increasing the use of non-VHA care. The report recommends conducting better assessments of civilian provider capacity, assessing the impact of trainings in cultural competency on provider capacity, expanding access to effective trainings in selected evidence-based approaches, and facilitating providers' use of evidence-based approaches. 
subsections: section_title: Appendix. Public Laws Addressing VHA Suicide Prevention Efforts
paragraphs: Since Operations Enduring Freedom and Iraqi Freedom began, five public laws have addressed VHA suicide prevention efforts. Relevant provisions of each are summarized below.
Joshua Omvig Veterans Suicide Prevention Act
The Joshua Omvig Veterans Suicide Prevention Act ( P.L. 110-110 ), enacted in 2007, required the VA Secretary to develop and implement a comprehensive suicide prevention program, and to report to Congress on the program. The Congressional Budget Office (CBO) estimated that implementing the Joshua Omvig Veterans Suicide Prevention Act would have "little, if any, cost," because the VA already had implemented or was planning to implement each of the specific requirements. The textbox below lists the required elements and additional authorized elements of the comprehensive suicide prevention program.
National Defense Authorization Act for Fiscal Year 2008
Section 1611 of the National Defense Authorization Act for Fiscal Year 2008 ( P.L. 110-181 ) directed the VA and DOD Secretaries to jointly develop a comprehensive care and transition policy for servicemembers recovering from serious injuries or illnesses related to their military service. The law specified that the policy must address (among other things) the training and skills of health care professionals, recovery coordinators, and case managers, to ensure that they are able to detect and report early warning signs of suicidal thoughts or behaviors, along with other behavioral health concerns. The law further specified that the policy must include tracking the notifications made by recovery care coordinators, medical care case managers, and non-medical care managers to health care professionals regarding suicidal thoughts or behaviors, along with other behavioral health concerns. A 2009 Government Accountability Office report indicates that DOD and VA have developed the relevant policies.
Veterans' Benefits Improvement Act of 2008
Section 809 of the Veterans' Benefits Improvement Act of 2008 ( P.L. 110-389 ) grants the VA Secretary authority to advertise in the media for various purposes, including suicide prevention. Since enactment the VA has promoted the Veterans Crisis Line, for example, by placing advertisements on city buses and releasing public service announcements. 
Caregivers and Veterans Omnibus Health Services Act of 2010
Section 403 of the Caregivers and Veterans Omnibus Health Services Act of 2010 ( P.L. 111-163 ) requires the VA Secretary to conduct a study to determine the total number of veteran suicides (not limited to veterans using VA services) between January 1, 1999, and May 5, 2010 (i.e., the date of enactment). The in-progress study, dubbed the State Mortality Data Project, is described in a VA report published in February 2013. At the same time, the VA released a response to the report, which indicated (among other things) that a follow-up report was to be issued in May 2013. In January 2014, the VA released an update that includes some information about suicides among veterans who do not use VA health care services in 23 states. A full accounting of suicides among all veterans in all states has yet to be publicly released. 
Clay Hunt Suicide Prevention for American Veterans Act
Enacted on February 12, 2015, the Clay Hunt Suicide Prevention for American Veterans Act ( P.L. 114-2 ) has eight sections, including the short title (Section 1). Section 2 requires the VA Secretary to have an independent entity conduct annual evaluations of VHA mental health care and suicide prevention programs, with the first evaluation to be completed by the end of FY2018. Section 3 requires the VA Secretary to maintain a website with up-to-date information about VHA mental health care services. Section 4 requires the VA Secretary to undertake a three-year pilot program to repay the education loans of at least 10 eligible psychiatrists (or psychiatric residents in their final year of training) in exchange for two or more years of obligated service. Section 5 requires the VA Secretary to undertake a three-year pilot program to conduct community outreach in at least 5 of the VHA's 21 Veterans Integrated Service Networks (geographic regions). Section 6 authorizes the VA Secretary to collaborate with nonprofit mental health organizations and requires the VA Secretary to appoint a Director of Suicide Prevention Coordination to manage such efforts. Section 7 extends by one year (beginning on the date of enactment) the existing five-year post-discharge period of enhanced enrollment in VHA health care for certain veterans. Section 8 prohibits new appropriations to carry out the act. The CBO estimated that implementing the act would cost $24 million over six years (2015–2020).