VA provides care to veterans with mental health needs through its 150 VAMCs, which may include both specialty mental health care settings— including mental health clinics—and other settings that may provide mental health services but focus primarily on other types of care, such as primary care. VA has implemented a program to co-locate mental health care providers within primary care settings in an effort to promote effective treatment of common mental health conditions in the primary care environment while allowing mental health specialists to focus on veterans with more severe mental illnesses. According to VA, the prevalence of MDD in primary care settings among veterans being treated through VA is higher than that among the general population. MDD is characterized by the presence of depressed mood or loss of interest or pleasure along with other symptoms for a period of at least 2 weeks that represent a change in previous functioning. VA has policies and guidance in place related to treating veterans with MDD. For example, the Uniform Mental Health Services in VA Medical Centers and Clinics handbook (Handbook), which defines VA’s minimum clinical requirements for mental health services, requires that VA facilities provide evidence-based treatment through the administration of medication, when indicated, consistent with the MDD CPG. The CPG is guidance intended by VA to reduce current practice variation between clinicians and provide facilities with a structured framework to help improve patient outcomes. The MDD CPG provides evidence-based recommendations as guidance for clinicians who provide care for veterans with MDD. The MDD CPG includes approximately 200 recommendations to provide information and assist in decision making for clinicians who provide care for adults with MDD.assessments of depressive symptoms, such as the nine item Patient Health Questionnaire (PHQ-9), should be used at the initial assessment of MDD symptoms, to monitor treatment response at 4-6 weeks after initiation of treatment, after each change in treatment, and periodically For example, the CPG recommends that standardized thereafter until full remission is achieved.assessment is effective 4-6 weeks after initiation of treatment, making timely follow-up visits an important part of clinicians’ ability to assess whether the current treatment plan is effective or should be modified. According to the MDD CPG, veterans with MDD treated with antidepressants should be closely observed, particularly at the beginning of treatment and following dosage changes, to maximize veterans’ recovery and to mitigate any negative treatment effects, including worsening of depressive symptoms. The CPG should not take the place of the clinician’s clinical judgment. Beginning in June 2006, VA implemented several initiatives aimed at suicide prevention, including appointing a National Suicide Prevention Coordinator, developing data systems to increase understanding of suicide among veterans and inform VA suicide prevention programs, and instituting suicide prevention programs in VAMCs throughout the country. Additionally, VA Central Office established the Center of Excellence for Suicide Prevention and the Veterans Crisis Line in 2007. The Center of Excellence collects VA suicide prevention program data, which provides information on veteran suicide completions and suicide attempts for veterans receiving VA care, as well as those veterans not receiving VA care. VA’s Veterans Crisis Line provides toll-free, confidential support 24 hours per day for veterans, their families, and their friends through phone, online chat, or text message.Crisis Line fielded approximately 287,000 calls, 54,800 online chats, and 11,300 text messages. In fiscal year 2013, the Veterans As part of VAMCs’ suicide prevention programs, the Handbook requires each VAMC to have a suicide prevention coordinator whose responsibilities include establishing and maintaining a list of veterans assessed to be at high risk for suicide; monitoring these high-risk veterans; responding to referrals from staff and the Veterans Crisis Line; collaborating with community organizations and partners; training staff members who have contact with veterans at the VAMC, community organizations, and partners; and collecting and reporting information on veterans who die by suicide and who attempt suicide. See appendix II for more information on VAMCs’ tracking of veterans at high risk for suicide. VA Central Office uses several mechanisms to collect data on veteran suicides to help improve its suicide prevention efforts. One such mechanism includes data submitted by suicide prevention coordinators at VAMCs on known veterans who die by suicide. Beginning in December 2012, VA Central Office began a national initiative to collect demographic, clinical, and other related information on veteran suicides as a quality improvement initiative to improve its suicide prevention efforts by identifying information that can be used by VA Central Office to develop policy and procedures to help prevent future veteran deaths. This initiative, the Behavioral Health Autopsy Program (BHAP), replaced previous VA Central Office requirements to collect data on completed suicides. VA Central Office officials explained that they transitioned to the BHAP initiative to collect more systematic and comprehensive information about suicides, to incorporate interviews of family members of those who die by suicide, and to collect more contextual information. According to VA, the BHAP quality initiative has been adapted from a traditional psychological autopsy research framework that emphasizes the importance of information from outside sources as well as from those within the health care setting. The BHAP initiative is being implemented by VA in four phases: Phase 1—Standardized chart reviews: VAMCs’ suicide prevention coordinators are required to complete standardized chart reviews for all veterans’ suicides known to VAMC staff and reported on or after These reviews include specific information on a October 1, 2012.veteran’s utilization of VA health care services, as well as a veteran’s mental health diagnoses and risk factors for suicide. VA Central Office has instructed suicide prevention coordinators to use all available information, including VA medical records and information from a veteran’s family members to complete the chart review. These reviews are submitted to VA Central Office through completion of a BHAP Post-Mortem Chart Analysis Template (BHAP template) and VA Central Office has provided suicide prevention coordinators with a BHAP Guide on how to complete the fields in the BHAP template. VA Central Office requires VAMCs to submit the BHAP template within 30 days of VAMC staff becoming aware of a veteran’s death by suicide. Phase 2—Interviews with family members: In fiscal year 2013, VA Central Office began conducting interviews with family members of veterans who have died by suicide to obtain information on suicide risks, barriers to care, and suggestions for new programs to prevent suicide. Phase 3—Clinician questionnaire: This phase, which has not yet been implemented, will include an interview with the last provider that saw the veteran prior to his or her death. VA officials stated that there are no plans to begin this phase within calendar year 2014, and they have not established a future time table for implementing this phase. Phase 4—Public record review: This phase, which has also not been implemented, will be used to locate public records to identify stressors in the veteran’s life, such as a bankruptcy or divorce. Officials stated that there are no plans to begin this phase within calendar year 2014, and they have not established a future time table for implementing this phase. Since beginning the BHAP initiative, VA Central Office has internally issued two interim reports on data and trends from the submitted BHAP templates as part of Phase 1. The reports include information for veterans who died by suicide, both with and without a history of VA health care service utilization. Analyses of data on demographic characteristics, case information, period of service, and risk and protective factors were included for all veterans. Data on clinical characteristics and indicators of increased risk at the time of the veteran’s last contact with a VA provider were limited to veterans that utilized VA health care services. In addition to the BHAP initiative, VA also requires VAMCs to collect and submit data on suicide attempts and completions through the following mechanisms. Suicide Prevention Application Network (SPAN): Through SPAN, VAMCs submit information to VA Central Office on the number of veterans that completed suicide, the number of suicide attempts, and indicators of suicide prevention efforts, such as outreach events conducted each month by suicide prevention coordinators. Suicide behavior reports: VAMC clinicians must complete a suicide behavior report when they learn that a veteran attempted or completed suicide and add that report to the respective veteran’s medical record. This report includes the date and time of the event, and other observations related to the suicide attempt or completed suicide. According to VA policy, information from suicide behavior reports is used for National Patient Safety reporting requirements and to populate SPAN. Root cause analyses: Patient safety managers at VAMCs complete root cause analyses for suicide attempts and completed suicides under certain circumstances, such as when the attempt occurs at the VAMC during an inpatient stay or within 72 hours of being discharged from inpatient care. Root cause analyses are used to identify the factors that contributed to adverse events or close calls and any steps VAMCs could implement to prevent similar events in the future. See appendix III for how VAMC and VISN officials we interviewed told us they have utilized data related to suicides and suicide behavior. Data for fiscal years 2009 through 2013 show that about 10 percent of veterans who received health care services through VA were diagnosed with MDD, and of those, 94 percent were prescribed an antidepressant. However, due to diagnostic coding discrepancies we found in a sample of veterans’ medical records, VA’s data may not accurately reflect the prevalence of MDD among veterans. Based on our analysis of VA data from veterans’ medical records and administrative sources, 532,222 veterans—about 10 percent of veterans who received health care services through VA—had a diagnosis of MDD from fiscal years 2009 through 2013. Among those veterans, the majority (60 percent) were 35 to 64 years of age. Most (86 percent) were In addition, not veterans of the recent conflicts in Iraq and Afghanistan.most of these veterans were male (87 percent) and the highest proportion was white (68 percent) and non-Hispanic (87 percent). See table 1 for a summary of characteristics of veterans who had a diagnosis of MDD from fiscal years 2009 through 2013. We also found that about 499,000 of the 532,222 (94 percent) veterans who had a diagnosis of MDD from fiscal years 2009 through 2013 were prescribed at least one antidepressant. Of those veterans, the majority (about 73 percent) were dispensed a 12-week supply of an antidepressant at the start of an MDD episode. Fewer veterans (about 58 percent) were dispensed a 6-month supply of an antidepressant over the course of their treatment. Receiving a 12-week supply of an antidepressant can be important for addressing depressive symptoms initially, while continued treatment after remission of depressive symptoms, such as receiving a 6-month supply of an antidepressant, is associated with a decreased risk of relapse, according to the CPG. Based on our review of the documentation in 30 veterans’ medical records from VA’s medical record system, we found that over one-third (11) had diagnostic coding discrepancies. Specifically, these 11 veterans had at least one encounter where the clinician documented a diagnosis of MDD in the veteran’s medical record, but the clinician did not code the encounter accordingly. Instead, the clinician coded the encounter as “depression not otherwise specified,” a less specific code. According to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, depression not otherwise specified is to be used to code disorders with depressive features that do not meet criteria for MDD and other depressive disorders, or to indicate depressive symptoms about which there is inadequate or contradictory information. VA’s data on the number of veterans with MDD are based on the diagnostic codes associated with patient encounters, so the discrepancies we found indicate that the number of veterans with MDD is most likely not fully reflected in these data. Accurately identifying the veteran population with MDD is critical to assessing Department performance in treating veterans in accordance with the MDD CPG and measuring health outcomes for these veterans. VA Central Office reviewed the 11 medical records where we found coding discrepancies and agreed that the encounters were not coded accurately. According to a VA Central Office official, the encounters we identified were corrected in the veterans’ medical record. According to VHA Handbook 1907.03 - Health Information Management Clinical Coding Program Procedures, VAMCs are required to monitor the accuracy of coding and provide training as necessary in order to help ensure accurate coding. VAMC officials from all six sites in our review said that monthly or quarterly coding audits are conducted at their facilities and the findings of those audits are reviewed and action is taken to correct issues with the accuracy and reliability of coding. However, at five of the six VAMCs in our review, those audits focus on billable encounters—that is, encounters that are billed to a third party, such as private health insurance plans—in part because of the potential opportunity for facilities to collect third-party revenue from these encounters. Among the 11 veterans’ medical records where we identified coding discrepancies, all of the discrepancies were associated with outpatient, nonbillable encounters, the coding of which, according to a VA Central Office official, is not typically conducted by VAMC medical coders—staff who are trained specifically in medical coding terminology and standards and are responsible for coding inpatient admissions and discharges—or subject to coding audits. Diagnostic coding in VA’s medical record system for outpatient encounters is typically performed by clinicians. VISN officials and VA medical center clinicians we interviewed said that clinicians do not place a lot of importance on selecting a more precise diagnostic code because it does not significantly change the patient care that is provided or the type of treatment prescribed. In addition, in the interest of expediency, clinicians may select a previously used or frequently used diagnostic code for depression rather than take the time to search for a more precise code. For example, within the medical record, clinicians may access a list of previous or current diagnoses applicable to the veteran (commonly referred to as the “problem list”) or a list of frequently used diagnostic codes in the facility. According to VISN and VAMC officials, the problem list is not typically kept up to date by clinicians and as a result, MDD may not be listed and readily available for clinicians to select. As a result of our review, VA Central Office officials reported that they had discovered a software mapping error in VA’s medical record system where the selection of MDD as a diagnosis when using a keyword search function may result in the selection of the depression not otherwise specified diagnostic code by mistake. Officials stated that they anticipate that the software error—which applies to all VAMCs—would be fixed by November 2014. Officials also stated that the solution would apply only to those encounters coded from that point going forward and would not retroactively correct any coding discrepancies that may have occurred before the error was addressed. VA Central Office officials could not tell us if any of the 11 coding discrepancies that we identified were a result of this software error. Officials at most of the six VISNs we spoke with do not conduct reviews of medical coding done by clinicians. However, as a result of our inquiry, one VISN we interviewed reported in the late spring of 2014 that it had extracted data on MDD-related encounters and noticed the high use of depression not otherwise specified coding for the facilities within its VISN, as well as all VAMCs nationwide. Officials from this VISN said the lack of coding specificity has implications for being able to accurately examine health outcomes related to the treatment of depression and that they are planning to further analyze encounter data within their VISN to determine the appropriateness of diagnostic coding based upon medical record documentation. As of September 2014, the VISN had not reported any additional steps to address this issue. Based on the three CPG recommendations we selected, veterans in our review with MDD who have been prescribed antidepressants did not always receive care as recommended in the MDD CPG. Additionally, VA does not know the extent to which veterans with MDD who have been prescribed antidepressants are receiving care as recommended in the CPG, and VA Central Office has not developed mechanisms to determine the extent to which mental health care delivery conforms to the recommendations in the MDD CPG. We found that almost all of the 30 veterans with MDD who have been prescribed antidepressants included in our review did not receive care in accordance with the three MDD CPG recommendations we reviewed. VA policy states that antidepressant treatment must be consistent with VA’s current, evidence-based CPG. However, VA Central Office mental health officials were unable to tell us what it means to provide care that is consistent with the CPG, because, while a veteran’s treatment should be informed by the CPG recommendations, determining the extent to which the treatment is consistent with CPG recommendations would need to be done on a veteran-by-veteran basis. The CPG is intended to reduce practice variation and help improve patient outcomes, but without an understanding of the extent to which veterans are receiving care that is consistent with the CPG, VA may be unable to ensure that it meets the intent of the CPG and improves veteran health outcomes. Through our review of 30 medical records from the six VAMCs we selected, we found examples of deviations from the CPG recommendations for almost all veterans in our review.depicts the specific recommendations we reviewed and the number of veterans that did not receive care consistent with the corresponding CPG recommendation. VA does not know the extent to which veterans are receiving care consistent with the MDD CPG. While deviations from recommended practice may be appropriate in many cases due to clinician discretion, VA has not fully assessed whether these examples are acceptable deviations from the CPG. According to the federal internal control standard for risk assessment, agencies should comprehensively identify risks, assess the possible effects, if any, and determine what actions should be taken to mitigate any significant risks. VA Central Office has not developed a mechanism to fully identify deviations that could impede veterans’ recovery that may result when VAMCs do not provide care consistent with the MDD CPG. VA Central Office officials explained that the CPG recommendations are guidelines that clinicians can use to inform and guide clinical decision making. VA officials told us that VA cannot require the use of all recommendations in all cases; rather, CPG recommendations should be applied on a case-by-case basis based on the needs of the veteran and with clinician judgment. One official also said it would be difficult to check every CPG recommendation to ensure that clinicians are providing care consistent with the CPG, but stated that VA could identify for review those recommendations that may put veterans’ health at risk if not followed. However, with no mechanism to assess whether the care provided is consistent with the CPG, VA is unable to ensure that deviations from recommended care are identified. While monitoring full compliance with CPG recommendations may be difficult, there are nevertheless ways to address the issue. In fact, VA Central Office and some VAMCs have implemented mechanisms to determine the extent to which veterans are receiving care that is consistent with some of the CPG recommendations; however, these mechanisms do not fully assess all deviations that could impede a veteran’s recovery, as illustrated by the following. Officials at one VAMC we visited told us that they use a clinical tool to track veterans being treated for mental health conditions. The mental health tool includes 67,349 unique patients, and an official explained that they can run queries of the clinical tool—for example, for veterans participating in substance abuse treatment who did not return for a drug screen—by pulling both process and outcome variables including diagnostic codes, lab results, and medication lists. designed to manage the behavioral health needs of veterans through telephone or in-person visits. As part of the system, clinicians can use a structured interview—including a PHQ-9—that assesses veterans’ mental health symptoms in a way that is consistent with the CPG recommendation for follow-up assessment. Although the BHL can be used to help ensure care is provided consistent with a few of the recommendations in the CPG, the BHL is not used to monitor all veterans prescribed antidepressants. Generally, VAMCs use the BHL to monitor veterans being treated for mental health conditions, such as MDD, in primary care clinics, and to participate, veterans can be referred by their primary care clinician or request to participate. We found that demographic, clinical, and other data submitted to VA Central Office on veteran suicides were not always completely or correctly entered into the BHAP Post-Mortem Chart Analysis Templates— a mechanism by which VA Central Office collects veteran suicide data from VAMCs’ review of veterans’ medical records. (Figure 1 shows the number of BHAP templates we found with incomplete or inaccurate data.) Moreover, VAMCs interpreted and applied instructions for completing the BHAP templates differently. We also found that most VAMCs and VISNs we reviewed and VA Central Office did not review suicide data for accuracy. We found that over half of the 63 BHAP templates we examined had incomplete information.information, or other specific fields were omitted. Moreover, the data were lacking entirely for certain known veteran suicides. Incomplete data limits VA Central Office’s ability to identify information that can be used to help VA Central Office develop policy and procedures to prevent veteran deaths. The data either lacked veteran enrollment Lack of veteran enrollment information. Approximately one-third (23) of the BHAP templates we reviewed did not indicate whether the veteran was enrolled in VA health care services, even though the veteran had a VA medical record. Eight did not indicate that the veteran had received VA services when the templates were submitted by three of the VAMCs in our review, even though these VAMCs provided care to these veterans. Fifteen BHAP templates submitted by two VAMCs in our review originally indicated that the veteran was receiving VA care; however, when we reviewed the submitted BHAP templates we received from VA Central Office for the same 15 veterans, the BHAP templates did not indicate that the veteran was being seen in the VA. VA Central Office used enrollment information when compiling the most recent BHAP interim report, which is part of VA Central Office’s quality improvement efforts for its suicide prevention program. Specifically, VA Central Office included clinical data in the BHAP interim report only for veterans utilizing VA services. Therefore, clinical data for the 23 veterans we identified would not be included in the interim report. Missing one-third of the data from its analysis, as was the case in our sample, could have a detrimental effect on the trends VA Central Office reports and uses to improve its suicide prevention efforts. Requested data was omitted. Forty of the 63 BHAP templates we reviewed included various data fields where no response was provided, resulting in incomplete data. For example, for 19 templates, VAMC staff did not enter requested data as to whether the veteran had all or some of 15 active psychiatric symptoms within 12 months prior to the veteran’s date of death. Also, 9 templates did not include an answer for the number of previous suicide attempts by the veteran. Officials from one VAMC told us that they left this field blank if the veteran did not have any previous suicide attempts, rather than entering a “0,” even though the BHAP Guide states that officials should enter the appropriate number of previous suicide attempts. Officials at one VAMC told us that fields are sometimes left blank if the standardized answers available on the BHAP template are not adequate; that is, the answer for that veteran does not fit into one of the answers provided on the BHAP template. Officials at two VAMCs stated that it is sometimes easy to overlook fields in the BHAP template, resulting in unanswered questions. Filling in all fields in the BHAP template, rather than leaving the field blank, is important because some blank fields are counted as “missing” or “no” in the analysis conducted by VA Central Office for the BHAP interim reports. This, in turn, could affect the suicide trends reported. For example, for the number of previous suicide attempts, blank fields are counted as “missing” in the BHAP interim report, rather than “0” previous suicide attempts as officials from one VAMC intended. In other cases, such as for psychiatric symptoms, missing fields are counted as “no,” meaning that the veteran did not have these symptoms. In at least one BHAP template, the answer for the psychiatric symptom of isolation was left blank, and would therefore be counted as negative in the interim report despite the fact that officials from the one VAMC told us that the veteran did have this symptom. See figure 2, which provides an excerpt of the fields from the BHAP template in which VAMCs provided incomplete data. Data were lacking entirely for certain known veteran suicides. We found that VAMCs did not always submit BHAP templates for all veteran suicides known to the facility, as required by the BHAP Guide. VA Central Office does not have a process in place to determine whether it is receiving the BHAP templates for all known veteran suicides. For example, one VAMC had completed 13 BHAP templates at the time of our site visit but had not submitted them; however, neither the VAMC nor VA Central Office were aware that these templates had not been submitted until after we requested them from VA Central Office. The suicide prevention coordinator at this VAMC told us that the BHAP templates were forwarded to another official at the VAMC, rather than being submitted through VA Central Office’s process, and that the BHAP templates were never submitted. As a result of our inquiry, the VAMC submitted these templates to VA Central Office. In another example, officials at a different VAMC told us that, at the time of our site visit, they had recently begun completing and submitting BHAP templates, beginning with veteran suicides occurring in fiscal year 2014. VA Central Office officials told us that VAMCs can start submitting BHAP templates at any point, and officials are not requiring the VAMCs to go back and submit information on all suicides since October 1, 2012. However, this practice is contrary to VA policy, which states that VAMCs should submit BHAP templates for all suicides known to the facility and reported on or after October 1, 2012. Of the 63 BHAP templates we reviewed, we found numerous instances of inaccurate data submitted on BHAP templates, as illustrated by the following examples. Incorrect date of death: Six BHAP templates included a date of death that was incorrect based on information in the veteran’s medical record. The difference in the dates of death in the veterans’ medical records and the dates of death in the BHAP templates ranged from 1 day to 1 year. For example, one BHAP template indicated that the veteran died in the year after the veteran’s actual date of death. Another BHAP template appeared to use the date the suicide behavior report was completed, rather than the veteran’s actual date of death. The suicide behavior report was completed 69 days after the veteran’s date of death.in the BHAP template is important because it is used as a point of reference to calculate other fields, such as the number of mental health visits in the last 30 days. The accuracy of the date of death recorded Incorrect number of mental health visits: Nine BHAP templates included the incorrect number of outpatient VA mental health visits in the last 30 days. For example, one BHAP template indicated that the veteran had five outpatient mental health visits, including three non-mental health visits that should not have been included in the total number of mental health visits for this veteran. Another BHAP template indicated the veteran had been seen once by a mental health provider in the last 30 days; however, we found in reviewing the medical records that this veteran had not been seen by a mental health provider during this time period. This veteran would be included in the BHAP interim report as having a mental health visit, and, as a result, VA’s data would include an inaccurate count of the number of veterans with mental health visits in the last 30 days.accurate information, VA cannot use this information to determine whether policies or procedures need to be changed to ensure that Without veterans at high risk for suicide are being seen more frequently by a mental health provider to help prevent suicides in the future. See figure 3, which provides an excerpt of the fields from the BHAP template in which VAMCs provided inaccurate data. We found several situations where VAMCs interpreted and applied instructions for completing the BHAP templates differently, as illustrated in the following examples. We found inconsistencies in how different VAMCs arrived at answers provided in the BHAP templates. For example, one VAMC included a visit to an immunization clinic as the veteran’s final visit, while another VAMC did not include this type of visit, even though this was the last time the veteran was seen in person. The BHAP Guide indicates that the final visit should be the last time the veteran had in-person contact with any VAMC staff, but the BHAP Guide does not identify the different types of visits that should be counted. VA Central Office officials stated that a visit to an immunization clinic should be included as the final visit with the veteran. When VAMCs do not provide consistent data, VA Central Office will receive and use inconsistent data in preparing its trend reports, such as BHAP interim reports, which are intended to be used to improve suicide prevention efforts. We also found instances in which BHAP templates included information that did not conform to the instructions in the BHAP Guide on how to complete the BHAP medical record reviews. Last contact did not always represent the last time a VAMC official spoke with the veteran: The BHAP Guide instructions specify that the last contact recorded in the BHAP template should be the last recorded interaction with the veteran, which could be in person, through a phone call, or through email. Five of the 63 BHAP templates we reviewed did not indicate the last time an official spoke directly to the veteran. One BHAP template counted a phone call with a veteran’s spouse after the veteran’s death as the last contact with the veteran. The BHAP template also counted this phone conversation as an “in-person” interaction. The remaining four BHAP templates included a date for the last contact that was prior to the date for the veteran’s final in-person visit at the VAMC. In these instances, the veterans’ in-person visit should have been counted as the last contact. From this flawed information, VA would not be able to determine reliable trends for the amount of time between the last contact with the veteran and the veteran’s date of death for reports that it prepares, such as the BHAP interim report. Suicide prevention coordinator contact and referral not within BHAP time period: The BHAP Guide specifies that VAMCs should indicate in the BHAP template whether there was a suicide prevention coordinator contact or referral made within 3 months prior to the veteran’s date of death. In 3 of the 63 cases we reviewed, we found that the suicide prevention coordinators checked the box indicating that they saw the veteran or had a referral within 3 months of the veteran’s death. However, in each of these cases we found that the contact was made more than 3 months prior to the veteran’s death, so it should not have been counted. A suicide prevention coordinator from one VAMC said she was unaware of the time period requirement and a suicide prevention coordinator at another VAMC stated that time frames should be added to the BHAP template, rather than just included in the BHAP Guide. The BHAP interim reports include the number of veterans that had a suicide prevention coordinator contact or referral, and by including information on contacts or referrals that are outside the BHAP Guide time frame, these reports may be at risk of misreporting trends in this area. See figure 4, which provides an excerpt of the fields from the BHAP template in which VAMCs provided inconsistent data. VA policy and guidance states that the BHAP template should be completed for all suicides known to the facility, but at the five VAMCs we visited, these data were not always being reported. However, the policy and instructions do not explicitly state that veterans not being seen by VA should be included, and in the absence of this declaration, some VAMCs interpreted the instructions to mean that only veterans being seen by VA should be included in the data submitted. Therefore, two VAMCs have submitted data only for veterans being treated by VA, while the others include data on all known veteran suicides—whether they have been treated by VA or not. This further adds to the inconsistencies in the information that VAMCs submit on the BHAP templates. VA Central Office officials told us that BHAP templates should be completed for both veterans utilizing VA health care services, as well as those veterans not being seen in the VA, and that this requirement has been discussed at training sessions and during conference calls with suicide prevention coordinators. For example, during a suicide prevention conference in November 2013, a VA Central Office official informed participants that the BHAP template should be completed for all suicides reported through SPAN, which VA Central Office officials previously told us includes veterans that were not receiving VA care. The inconsistency in VAMC officials’ understanding of which veterans should have a completed BHAP template results in inconsistent data being reported to VA Central Office. While VA was in the process of updating its suicide prevention coordinator manual, we brought this issue to VA’s attention. In August 2014, VA made modifications to the manual that indicated that VA is changing its policy—now requiring that the BHAP template should be completed only for veterans receiving VA services. However, the guidance continues to be unclear on whether suicide prevention coordinators should complete BHAP templates for veterans not receiving VA care. We found that BHAP templates are not being reviewed by VA officials at any level for accuracy, completeness, and consistency. Therefore, our findings at five VAMCs could be symptomatic nationwide and other VAMCs may also be submitting incomplete, inaccurate, and inconsistent suicide-related information and VA may not be getting the data it needs across the Department to make appropriate resource decisions and develop new policy. VA policy states that it is the VISN’s and VAMC’s decision whether to conduct reviews of BHAP data prior to submission to VA Central Office. With few exceptions, VAMCs and VISNs we visited generally do not conduct data checks on the information submitted in the BHAP templates. Additionally, VA Central Office does not review the information for accuracy and completeness in the BHAP templates it receives. This approach is inconsistent with internal control standards for the federal government, which state that agencies should have controls over information processes, including procedures and standards to ensure the completeness and accuracy of processed data. Officials at one VAMC told us that VAMC staff compare the BHAP data and the veteran’s medical record prior to submitting the BHAP template to VA Central Office to ensure accuracy. In response to our review, another VAMC implemented a procedure to check the accuracy and completeness of their BHAP templates prior to submission. The procedure at this VAMC requires the suicide prevention coordinator and case manager to independently complete the BHAP template and compare their responses. The BHAP templates are then reviewed by the Assistant Mental Health Clinic Director prior to submission. We also found that VA lacks sufficient controls to ensure the quality of the existing BHAP data. For example, VA Central Office officials said there are no automated data checks to ensure the accuracy of data it uses for the BHAP interim report, such as checking to ensure that the date of last contact with the veteran that is recorded in the BHAP template is not after the veteran’s date of death. Although officials removed apparent duplicates in submitted BHAP templates by matching the veteran’s name and social security number while compiling the data for the most recent BHAP interim report, they do not conduct data checks to help identify some of the incomplete or inaccurate data we found in our review. Given the negative effects of MDD, it is important to provide timely, evidence-based treatment for veterans with MDD, and VA’s ability to monitor these veterans is critical to ensuring positive outcomes. However, our findings demonstrate that VA may not be fully aware of the population of veterans with MDD due to a lack of coding precision by clinicians. This can limit VA’s ability to assess the Department’s performance in treating veterans as recommended in the MDD CPG and in measuring health outcomes for veterans. Additionally, VA does not have mechanisms in place to ensure that the Department is able to identify deviations from CPG-recommended care and remedy those that could impede veterans’ recovery. Even if VA did have mechanisms in place, the coding discrepancies we identified would limit VA’s ability to extract accurate data on all veterans diagnosed with MDD, therefore hindering VA’s ability to determine the extent to which veterans are receiving care consistent with the CPG recommendations for MDD. The CPG recommendations are meant to improve veteran outcomes by providing maximum relief from the debilitating symptoms of MDD, and VA cannot ensure that the care veterans receive is consistent with those recommendations. The existence of incomplete, inaccurate, and inconsistent information submitted through VA’s BHAP templates limits the Department’s ability to accurately evaluate its suicide prevention efforts and identify trends in veteran suicides through the BHAP initiative. Specifically, data drawn from incomplete, inaccurate, and inconsistent BHAP templates limit the Department’s opportunities to learn from past veteran suicides and ultimately diminish efforts to improve its suicide prevention activities. VAMCs, VISNs, and VA Central Office generally lack a process to ensure that the data that are submitted and used by VA Central Office to identify trends in veteran suicides are complete, accurate, and consistent. Checking and verifying the data submitted to VA Central Office would help ensure that changes made to suicide prevention efforts by VAMCs, VISNs, and VA are based on actual trends in veteran suicides. Without clear VA Central Office instructions to guide how VAMCs and VISNs should complete BHAP templates and report suicide data, the validity of suicide data and the effectiveness of VA’s actions will be hampered. We recommend that the Secretary of Veterans Affairs direct the Under Secretary for Health to take the following six actions: To more accurately estimate the prevalence of MDD and identify enrolled veterans with MDD, VA should identify the extent to which there is imprecise diagnostic coding of MDD by further examining encounters with a diagnostic code of depression not otherwise specified, which could be incorporated into VAMCs’ ongoing review of diagnostic coding accuracy, and determine and address the factor(s) contributing to the imprecise coding based on the results of those examinations. For example, feedback and additional training could be provided to clinicians regarding the importance of diagnostic code accuracy, or VA’s medical record could be enhanced to facilitate the selection of a more accurate diagnostic code. To ensure that veterans are receiving care in accordance with the MDD CPG, VA should implement processes to review data on veterans with MDD prescribed antidepressants to evaluate the level of risk of any deviations from recommended care and remedy those that could impede veterans’ recovery. To improve VA’s efforts to inform its suicide prevention activities, VA should ensure that VAMCs have a process in place to review data on veteran suicides for completeness, accuracy, and consistency before the data are submitted to VA Central Office, clarify guidance on how to complete BHAP templates to ensure that VAMCs are submitting consistent data on veteran suicides, and implement processes to review data on veteran suicides submitted by VAMCs for accuracy and completeness. We provided a draft of this report to VA for comment. In its written comments, reproduced in appendix IV, VA generally agreed with our conclusions and concurred with our recommendations. In addition, VA provided information on its plans for implementing each recommendation, with estimated completion dates in calendar year 2015. As agreed with your office, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report’s date. At that time, we will send copies of this report to the appropriate congressional committees; the Secretary of Veterans Affairs; the VA Under Secretary for Health; and other interested parties. In addition, the report will be available at no charge on the GAO website at http://www.gao.gov. If you or your staff have any questions, please contact me at (202) 512- 7114 or williamsonr@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. Major contributors to this report are listed in appendix V. To describe the characteristics of veterans diagnosed with MDD from fiscal years 2009 through 2013, we analyzed Department of Veterans Affairs (VA) and Department of Defense (DOD) data. (See table 3.) These data included information on veterans’ demographic characteristics as well as clinical information on health care services and medications provided through VA. Veterans were classified as having a diagnosis of MDD if, in at least one fiscal year included in our review, they had two or more outpatient encounters or at least one inpatient hospital stay with a diagnosis of MDD. Specifically, we examined the following: Number of veterans diagnosed with MDD. We used a demographic file provided by VA to determine the number of veterans diagnosed with MDD. Characteristics of veterans diagnosed with MDD. We used demographic files provided by VA and DOD to describe characteristics of veterans diagnosed with MDD. In particular, the veteran characteristics we examined included the following: Age. We created seven categories for veterans’ ages as of September 30, 2013—the end of fiscal year 2013, which corresponds to the last date of data we included in our analysis. These categories are as follows: (a) 18-24, (b) 25-34, (c) 35-44, (d) 45-54, (e) 55-64, (f) 65-74, and (g) 75 and older. Era of service. We categorized veterans as either being veterans of the recent conflicts in Iraq and Afghanistan—Operation Iraqi Freedom, Operation Enduring Freedom, and Operation New Dawn—or of other eras of service. Sex. We categorized veterans as either being female or male. Race and ethnicity. We created categories to describe veterans’ race and ethnicity (Hispanic and non-Hispanic). These categories are consistent with the Office of Management and Budget’s 1997 Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity. Extent to which veterans diagnosed with MDD were prescribed at least one antidepressant. Using data from the Pharmacy Benefits Management database, we examined the extent to which VA providers prescribed at least one antidepressant for veterans diagnosed with MDD from fiscal years 2009 through 2013. This includes antidepressants prescribed to treat depression as well as those prescribed to treat other conditions. The percentage of veterans with MDD dispensed a 12-week and a 6-month supply of an antidepressant. Using VA data we obtained from the Medical SAS Inpatient Datasets, Acute Care Dataset; Outpatient Encounter Files; Fee Basis Outpatient and Inpatient Services Files; and Pharmacy Benefits Management Database, we calculated the percentage of veterans with MDD dispensed a 12-week and a 6-month supply of an antidepressant according to statistical programming logic provided by VA. These measures are intended to assess the effectiveness of antidepressant medication management and are based on performance measures developed by the National Committee for Quality Assurance. In addition, these measures are consistent with the VA/DOD Clinical Practice Guideline for Management of Major Depressive Disorder, which indicates that continued antidepressant treatment, after acute depressive symptoms have resolved, decreases the incidence of relapse of MDD. We selected six VA medical centers (VAMC) at the following locations to visit: Canandaigua, New York; Gainesville, Florida; Iowa City, Iowa; Philadelphia, Pennsylvania; Phoenix, Arizona; and Reno, Nevada. These VAMCs represent different facility complexity groups, serve populations of veterans that differ in terms of the extent of use of mental health services, and are located in different Veterans Integrated Service Networks (VISN), To gather additional perspectives, for each or regional networks of care.VAMC we visited, we selected one associated community-based outpatient clinic to visit. In particular, we visited community-based outpatient clinics in the following locations: Cedar Rapids, Iowa; Globe, Arizona; Gloucester, New Jersey; Lecanto, Florida; Fallon, Nevada; and Rochester, New York. (See table 4.) As part of our site visits, we reviewed a nongeneralizeable sample of five medical records for each of these six VAMCs for a total of 30 veterans. We reviewed these medical records to determine if the diagnostic code entered for all encounters— starting with the initial encounter in 2012 when the veteran was diagnosed with MDD and prescribed an antidepressant—was consistent with a diagnosis of MDD. To select medical records for review, we completed the following steps: Randomly generated a list of individuals with a new prescription for an antidepressant in calendar year 2012. Selected the first five individuals in the list that met the following Veteran status. Had a diagnosis of MDD in calendar year 2012. For the purposes of medical record reviews, we classified a veteran as having a diagnosis of MDD if, based on how the veteran’s patient care encounters were coded or on the narrative contained in clinical notes in the veteran’s medical record, the veteran had (a) at least two outpatient encounters with a diagnosis of MDD, or (b) at least one inpatient stay with a diagnosis of MDD. Had a new treatment episode of antidepressants in calendar year 2012. New treatment episodes were defined as an initiation of antidepressant treatment following a period during which the veteran was either (1) not prescribed an antidepressant or (2) noncompliant with and had not picked up prescriptions for a previously prescribed antidepressant. To ensure the reliability of the data we analyzed, we interviewed VA Central Office officials, reviewed relevant documentation and veterans’ medical records, and conducted electronic testing to identify missing data and obvious errors. On the basis of these activities, we determined that the data we analyzed were sufficiently reliable for our purposes. However, as discussed in the report, we described limitations of the data due to the coding discrepancies we found. To examine the extent to which VAMCs are providing care to veterans with MDD who are prescribed antidepressants as recommended in the CPG, we reviewed relevant VA policy documents. On the basis of that review, we found that VA policy requires all care sites, VAMCs, and community-based outpatient clinics to provide evidence-based antidepressant treatment when indicated for depression and that such care must be consistent with current VA clinical practice guidelines. The relevant VA clinical practice guideline, the VA/DOD Clinical Practice Guideline for Management of Major Depressive Disorder, provides evidence-based recommendations for providers on how to monitor veterans prescribed antidepressants; these recommendations are based on a review of depression research outcomes. These recommendations are based on available research at the time of publication of the guideline and are intended to provide information to assist providers in treatment decision-making.monitoring veterans prescribed antidepressants, we judgmentally selected three recommendations for inclusion in our review. In particular, we selected recommendations that (1) had among the highest strength of research evidence, (2) were sufficiently specific to enable us to determine the extent to which VA providers were following the recommendation, and (3) would not require clinical judgment to determine the extent to which VA providers were following the recommendation. The following recommendations were included in our review: From the guideline’s recommendations related to To enhance antidepressant treatment, veterans should be educated on when to take the medication, possible side effects, risks, and the expected duration of treatment, among other things; Standardized assessments of depressive symptoms, such as the Patient Health Questionnaire-9, should be used to monitor treatment response at 4-6 weeks after initiation of treatment, after each change in treatment, and periodically thereafter until full remission is achieved; and A plan should be developed that addresses the duration of antidepressant treatment, among other things. After selecting these recommendations for our review, we examined the extent to which veterans were receiving care consistent with these CPG recommendations at the six VAMCs we visited. To do this, we interviewed VAMC clinicians to determine whether and how they were following these recommendations. At each VAMC, officials interviewed included members of the executive leadership team, primary care and mental health providers, and pharmacists. Additionally, as part of our examination of the extent to which VAMCs are providing care consistent with the selected guideline recommendations, we reviewed the sample of five veterans’ medical records per VAMC used as part of our review of MDD coding. For each medical record, we reviewed documentation contained in the selected veterans’ medical records to assess the extent to which the antidepressant treatment- related care VA providers rendered was consistent with the selected CPG recommendations included in our review. Our review commenced with the encounter during which a VA clinician ordered an antidepressant to treat depressive symptoms. Our review ended after five follow-up encounters with a VA clinician, or sooner if the veteran did not have five follow-up encounters. Our review was limited to encounters during which the antidepressant treatment was reviewed, including encounters during which side effects and treatment effect were assessed, but no change was made to medication orders. We did not include, for example, an encounter with an orthopedist during which the fact that the veteran had been prescribed an antidepressant was simply noted. We provided the VAMCs with the instances where we found the medical record documentation was not consistent with the selected CPG recommendations. The VAMCs confirmed our answers or provided additional support if they believed the care was consistent with the CPG. To examine VA’s oversight of the care VAMCs provide to veterans with MDD who are prescribed an antidepressant, we reviewed VA’s oversight of the Uniform Mental Health Services in VA Medical Centers and Clinics handbook and CPG requirements and evaluated whether this oversight provides VA with adequate information to identify nonconformance with recommended practices, assess the risk of any nonconformance, and address nonconformance, as appropriate. As part of this review, we reviewed VA’s oversight in the context of federal standards for internal control for risk assessment.refers to an agency’s ability to comprehensively identify risks, assess the possible effect, if any, and determine what actions should be taken to mitigate significant risks. The internal control for risk assessment We then interviewed officials from VA Central Office, including officials from the Office of Mental Health Services (OMHS), the Office of Mental Health Operations, and the Office of Analytics and Business Intelligence; and the six VISNs that oversee the VAMCs we visited who are responsible for overseeing compliance with VA’s requirements, including VA’s requirement that all VA facilities provide evidence-based antidepressant treatment when indicated for depression and that such care be consistent with current VA clinical practice guidelines. Through our interviews, we obtained information on the oversight activities conducted by VA Central Office and the extent to which VA Central Office followed up with VAMCs to ensure that they corrected problems identified through these oversight activities. In addition, we obtained and reviewed relevant documents regarding VA oversight, including internal reports and VAMCs’ plans to correct problems identified through oversight activities. To analyze the information VA requires VAMCs to collect on veteran suicides, we first reviewed VA policies, guidance, and documents related to VA’s suicide prevention efforts to identify the mechanisms by which VA collects veteran suicide data from VAMCs. We also interviewed VA Central Office and other officials responsible for VA’s suicide prevention program, including officials from OMHS and the Center of Excellence for Suicide Prevention. We also interviewed VAMC officials and relevant staff of the six VISNs for the sites we visited to obtain information on suicide prevention initiatives. Next, through the site visits to six VAMCs, we obtained documents and interviewed officials regarding the collection of veteran suicide data. We obtained all completed templates from the Behavioral Health Autopsy Program (BHAP) related to VA’s collection of data on veterans that died by suicide as of the time of our site visit or at the time we requested the One VAMC had not completed any of documents for virtual site visits.these BHAP documents because they had not had a veteran die by suicide since the beginning of the program. Therefore, our analysis includes a review of documents from five of the six VAMCs we visited. Through review of the documents, we noted any fields missing data, such as a field that requires a yes or no answer but neither answer is provided. Additionally, using professional judgment, we identified fields in the documents to review based on whether the field related to aspects of VA treatment—including treatment for mental health conditions—and the date of the veteran’s death. We identified these fields because they did not require clinical judgment to assess. Using the parameters in the corresponding guide for filling out these documents, including time frames, we compared these fields to information included in the veteran’s medical record and noted differences between our answers and the answers provided by the VAMCs in the documents. To ensure that we received the final, submitted versions, we also requested these documents from VA Central Office for each of the five VAMCs. We compared these documents to the documents we received from the VAMCs. We used the documents from the VAMCs as the starting point; therefore, we only analyzed the templates for veterans identified by the VAMCs. that the template for these documents had changed over time. If additional fields were included in the templates obtained from VA Central Office, but were not originally included in the templates obtained from the VAMCs, we did not review these fields. We generally used the answer from the document obtained from VA Central Office, which is the final submitted version, unless a field originally had an answer in the template from the VAMC, but was blank or not answered in the template from VA Central Office. In those cases, we used the answer from the VAMC document. During the course of our review we learned We provided the VAMCs with the fields where the answers in the VAMC’s documents did not match our answers based on our review of the medical record. The VAMCs confirmed our answers or provided additional support for their original answer. Results from our review of veteran suicide data can be generalized to the VAMCs we visited, but cannot be generalized to other VAMCs. We received additional templates from VA Central Office, but these were not analyzed because the VAMC had not provided us with templates for these veterans. We conducted this performance audit from November 2013 to November 2014 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. The Department of Veterans Affairs’ (VA) Uniform Mental Health Services in VA Medical Centers and Clinics handbook (Handbook) requires VA medical centers (VAMC) to have a suicide prevention coordinator whose responsibilities include establishing and maintaining a list of veterans assessed to be at high risk for suicide and monitoring these veterans. The Handbook also requires suicide prevention coordinators to ensure that providers follow up on missed appointments for high-risk veterans to ensure patient safety and in order to initiate problem-solving about any tensions or difficulties in the veteran’s ongoing care. Whether a veteran is determined to be at high risk for suicide is based on clinical judgment made after an evaluation of risk factors—such as history of past suicide attempts or recent discharge from an inpatient mental health unit—protective factors—such as positive social support, positive coping skills, and positive therapeutic relationships—and the presence or absence of warning signs. Indicators that a veteran is at high risk for suicide include a current verified report or witnessed suicide attempt; identification of current serious suicidal ideation that requires an immediate change in the treatment plan, such as hospitalization; and the presence of any of the following warning signs: threatening to hurt or plan to kill oneself; looking for specific ways to kill oneself and seeking access to such means, such as pills or weapons; and talking or writing about death, dying, or suicide when these actions are out of the ordinary for the person. The Handbook requires each VAMC to have a process for establishing a patient record flag to help ensure that veterans determined to be at high risk for suicide are provided with follow up for all missed mental health and substance abuse appointments. The primary purpose of the patient record flag is to communicate to staff that a veteran is at high risk for suicide and VA policy states that the presence of a flag should be considered when making treatment decisions. Suicide prevention coordinators are responsible for assessing, in conjunction with the treating clinician, the risk of suicide in individual veterans, ensuring these veterans have a “High Risk for Suicide” Patient Record Flag on their medical record, and reviewing the list of high-risk veterans at least every 90 days. We interviewed suicide prevention coordinators as part of our site visits with six VAMCs to obtain information on how they track veterans determined to be at high risk for suicide. At four of the VAMCs we visited, suicide prevention coordinators used an electronic spreadsheet to track information on these veterans. For example, the spreadsheets include information such as whether the veteran has a patient record flag on their medical record and when the flag needs to be reviewed, the date for the veteran’s next scheduled follow-up appointment, whether the veteran has a safety plan, and the veteran’s assigned psychiatrist. Officials from one VAMC told us that they maintain the list daily, adding and removing veterans as necessary. Officials stated that the circumstances under which a veteran would be removed from the spreadsheet varied, but veterans are generally removed because their patient record flag has been removed and the officials no longer consider the veteran to be at high risk for suicide. The two remaining VAMCs use other mechanisms to track veterans at high risk for suicide. Officials from one VAMC told us that they use the Suicide Prevention Application Network (SPAN) to query high-risk patients at the VAMC. The SPAN database contains veteran information, demographic characteristics, and information on suicide attempts and completed suicides, among other things. According to officials, the information for each veteran in SPAN includes the date the veteran was assessed as being at high risk, as well as the date that the veteran needs to be seen for follow up, if applicable. After our site visit, officials told us they plan to periodically pull a list of all veterans with an active high risk flag in VA’s medical record for the VAMC and cross-reference that list to veterans being tracked for high suicide risk by the suicide prevention coordinator in SPAN to ensure all high-risk veterans are tracked. Officials from the other VAMC told us that their case managers each have their own list of veterans that they track and the suicide prevention coordinator we spoke with stated that he does not keep a master list of all veterans that are at high risk for suicide. Veterans Affairs medical centers (VAMC) collect and submit data on veteran suicides to the Department of Veterans Affairs (VA) Central Office through the Suicide Prevention Application Network (SPAN) and suicide behavior reports. VAMCs also collect and report data through root cause analyses. Additionally, VA Central Office uses the data from SPAN to prepare reports that are sent to the VAMCs and Veterans Integrated VA Central Office officials stated that they Service Networks (VISN).expect VAMCs and VISNs to use these reports and collected data to improve suicide prevention efforts and program evaluation. Through site visits at six VAMCs that we conducted as part of our review and through interviews with corresponding VISN officials, we identified examples of how some VAMCs and VISNs are utilizing veteran suicide data to improve their suicide prevention efforts. VAMC and VISN officials have used SPAN to create initiatives based on trends in the data. For example, Officials at one VAMC stated that they use the information collected in SPAN to provide data for performing statistical analyses on the outreach conducted, to study suicide attempts and completions across the VAMC catchment area, to understand the means by which veterans are dying by suicide, and to study the use of high-risk flags. Officials at a VISN explained that through a review of the SPAN data about a year ago, officials learned that 60 percent of suicides in the VISN were completed using a gun. After conducting research on the subject, the VISN began a firearm safety initiative, which includes notifying veterans by mail that they can receive four gun locks each upon request, with no questions asked. VAMC officials have made programmatic changes to their suicide prevention efforts based on trends in the suicide data they are collecting and reviewing. For example, At one VAMC, officials told us that they reviewed suicide behavior reports and, as a result of trends identified in these reports, drafted a policy for medication restriction for veterans at risk of overdosing. Specifically, over a 3-year period, five or six veterans receiving VA care repeatedly attempted suicide by overdose, typically when they were intoxicated. VAMC officials created a work group to draft policy that mitigates risk for medication overdose among high-risk veterans. At the time of our site visit, the group was exploring creating a patient record flag that would be included in the veteran’s medical record for overdose risk indicating that medication supplies should be restricted for these veterans and the possibility of using automated pill dispensers to dispense medications to these veterans. Through their work reviewing suicide-related information, the suicide prevention team at another VAMC identified a trend in its suicide data. In particular, they noted that some veterans were given a 90-day supply of the same medications that the veteran recently tried to use to overdose. The suicide prevention team mentioned this to a clinical pharmacist who had also noticed this issue. The VAMC is now trying to restrict days of supply for these types of veterans, but there is no formal policy about this and no plans to craft such a policy. Additionally, officials from this VAMC stated that they have added items to the standardized suicide behavior report template to help them to collect additional useful information, such as active medications and pain score at the time of the last visit. Officials from one VAMC stated that through a review of medical records and autopsy reports for veterans who died by suicide, they found that a vast majority of veterans who died by suicide were not being seen by a mental health provider. In response, officials provided education to primary care providers. VAMC officials also noticed that veterans receiving care for pain were dying by suicide at a high rate. As a result, the VAMC has started an initiative with the pain clinic, and, as part of this initiative, the chief of the pain management clinic consults with psychiatry on veterans at risk for suicide. Officials at a VISN described changes made in response to the suicide data in fiscal year 2012, which showed that a percentage of veterans who completed suicide had no ongoing mental health care. These veterans mainly received care from VA primary care providers. To address this, the VISN partnered with the Center of Excellence for Suicide Prevention and local university psychologists to help VA primary care providers at community-based outpatient clinics formulate mental health plans. Randall B. Williamson, (202) 512-7114, williamsonr@gao.gov. In addition to the contact named above, Marcia A. Mann, Assistant Director; Emily Binek; Muriel Brown; Stella Chiang; Cathleen Hamann; Melanie Krause; Daniel Lee; Lisa Opdycke; Sarah Resavy; and Jennifer Whitworth made key contributions to this report.

Summary: In 2013, VA estimated that about 1.5 million veterans required mental health care, including services for MDD. MDD is a debilitating mental illness related to reduced quality of life and productivity, and increased risk for suicide. VA also plays a role in suicide prevention. GAO was asked to review how VA tracks veterans prescribed antidepressants and what suicide data VA uses in its prevention efforts. This report examines (1) VA's data on veterans with MDD, including those prescribed an antidepressant; (2) the extent that veterans with MDD who are prescribed antidepressants receive recommended care and the extent to which VA monitors such care; and (3) the quality of data VA requires VAMCs to collect on veteran suicides. GAO analyzed VA data, interviewed VA officials, and conducted site visits to six VAMCs selected based on geography and population served. From each of these six VAMCs, GAO also reviewed five randomly selected medical records for veterans diagnosed with MDD and prescribed an antidepressant in 2012, as well as all completed BHAP templates. The results cannot be generalized across VA but provide insights. GAO's analysis of Department of Veterans Affairs (VA) data for fiscal years 2009 through 2013 shows that about 10 percent of veterans who received VA health care services were diagnosed with major depressive disorder (MDD). MDD is characterized by depressed mood or loss of interest along with other symptoms for 2 weeks or more that represent a change in the way individuals function from their previous behaviors. Because GAO found diagnostic coding discrepancies in 11 of the 30 veterans' medical records it reviewed from six VA medical centers (VAMC), VA's data may understate the prevalence of MDD among veterans being treated through VA, to the extent that such discrepancies may permeate VA's data. One treatment for MDD is the use of medications such as antidepressants. According to GAO's analysis, 94 percent of veterans diagnosed with MDD were prescribed at least one antidepressant. VA policy states that antidepressant treatment must be consistent with VA's current clinical practice guideline (CPG); however, GAO's review of 30 veterans' medical records identified deviations from selected MDD CPG recommendations for most veterans reviewed. For example, 26 of the 30 veterans were not assessed using a standardized assessment tool at 4 to 6 weeks after initiation of treatment, as recommended in the CPG. Additionally, 10 veterans did not receive follow up within the time frame recommended in the CPG. GAO found that VA does not have a system-wide process in place to identify and fully assess whether the care provided is consistent with the CPG. As a result, VA does not know the extent to which veterans with MDD who have been prescribed antidepressants are receiving care as recommended in the CPG and whether appropriate actions are taken by VAMCs to mitigate potentially significant risks to veterans. The demographic and clinical data that VA collects on veteran suicides were not always complete, accurate, or consistent. VA's Behavioral Health Autopsy Program (BHAP) is a quality initiative to improve VA's suicide prevention efforts by identifying information that VA can use to develop policy and procedures to help prevent future suicides. The BHAP templates are a mechanism by which VA collects suicide data from VAMC's review of veteran medical records. GAO's review of 63 BHAP templates at five VAMCs found that 40 of the templates that VAMCs submitted to VA Central Office had incomplete data. Also, GAO found that the BHAP templates VAMCs submitted contained inaccurate data. For example, 6 BHAP templates included a date of death that was incorrect based on information in the veteran's medical record, and 9 BHAP templates included an incorrect number of outpatient VA mental health visits in the last 30 days. Moreover, GAO found that VAMCs submitted inconsistent information because they interpreted VA's guidance on completing the BHAP templates differently. This situation was further exacerbated because BHAP templates prepared by VAMCs are generally not being reviewed at any level within the Department for completeness, accuracy, and consistency. Lack of complete, accurate, and consistent data and poor oversight can inhibit VA's ability to identify, evaluate, and improve ways to better inform its suicide prevention efforts. GAO recommends that VA identify and address MDD coding discrepancies; implement processes to review data and assess deviations from recommended care; and implement processes to improve completeness, accuracy, and consistency of veteran suicide data. VA concurred with GAO's recommendations and described its plans to implement them.