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. 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. 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. 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. 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. 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. 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. Suicide prevention interventions aim to reduce risk factors and/or enhance protective factors, thereby lowering the risk of suicide.