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).