VA provides care to veterans with mental health needs in VAMC primary and specialty care clinics. 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 clinical practice guideline (CPG) recommendations. 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, but should not take the place of the clinician’s clinical judgment. The MDD CPG includes approximately 200 evidence-based recommendations to provide information and assist in decision making for clinicians who provide care for adults with MDD. CPG recommendations describe, for example, the use of standardized assessments of veterans’ depressive symptoms as part of an evidence-based treatment plan. The Handbook requires VAMCs 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 veterans; responding to referrals from staff and the Veterans Crisis Line; and collecting and reporting information on veterans who die by suicide and who attempt suicide. intended to improve VA’s suicide prevention efforts by identifying demographic, clinical, and other related information on veteran suicides that VA Central Office can use to develop policy and procedures to help prevent future veteran deaths. VA Central Office officials explained that the BHAP initiative allows them to collect more systematic and comprehensive information about suicides, including information gleaned from interviews of family members of those veterans who die by suicide. VA Central Office has provided suicide prevention coordinators with a BHAP guide on how to complete the fields in the BHAP template. Our recent work, based on the three CPG recommendations we selected, has found almost all of the 30 veterans with MDD in our review who had been prescribed antidepressants received care that deviated from the MDD CPG recommendations. For example, we found that although the CPG recommends that veterans’ depressive symptoms be assessed at 4-6 weeks after initiation of antidepressant treatment using a standard assessment tool to determine the efficacy of the treatment, 26 of the 30 veterans were not assessed using such a tool within this time frame. Additionally, 10 veterans did not receive follow up within the time frame recommended in the CPG. Table 1 below depicts the specific recommendations we reviewed and the number of veterans that did not receive care consistent with the corresponding CPG recommendation. We also found that VA does not always know the extent to which veterans with MDD who have been prescribed antidepressants are receiving care as recommended in the CPG, and some clinicians at VAMCs we visited described instances in which they generally do not follow the CPG recommendations. For example, officials from two VAMCs we visited explained that they do not routinely use the nine item Patient Health Questionnaire (PHQ-9). According to officials at one of these VAMCs, the standard of care is to conduct a clinical interview and observation. However, the CPG recommendation states that the PHQ-9 combined with a clinical interview should be used to obtain the necessary information about symptoms and symptom severity. It also states that the PHQ-9 improves diagnostic accuracy and aids treatment decisions by quantifying symptom severity. Additionally, we found that VA Central Office has not developed a mechanism to determine the extent to which mental health care delivery in VAMCs conforms to the recommendations in 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. VA Central Office and some VAMCs have implemented limited methods to determine the extent to which veterans are receiving care that However, without is consistent with some of the CPG recommendations.a system-wide process in place to identify and fully assess whether the care provided is consistent with the CPG, 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 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, we concluded that VA may be unable to ensure that it meets the intent of the CPG and improves veteran health outcomes. To ensure that veterans are receiving care in accordance with the MDD CPG, we recommended that VA implement processes to review data on veterans with MDD who were prescribed antidepressants to evaluate the level of risk of any deviations from recommended care and remedy those that could impede veterans’ recovery. VA concurred with our recommendations and stated that VA would examine associations between treatment practices and indicators of veteran recovery or adverse outcomes. VA Central Office officials reviewed whether a cohort of veterans with MDD received treatment with an antidepressant that was in line with MDD CPG recommendations. However, in choosing CPG recommendations to review, VA officials told us that they chose the recommendations for review based on the ease of obtaining the needed data and because the antidepressant medication coverage measure is nationally recognized, rather than based on a methodical review of all of the CPG recommendations to identify those that may put veterans at risk and could impede veterans’ recovery if not followed, as we recommended in our November 2014 report. Therefore, it is not clear whether the CPG recommendations that VA chose to review were among those that may put veterans at risk and could impede recovery if not followed. Moreover, VA has not indicated whether it has implemented a process that will review CPG recommendations on an ongoing basis to identify deviations that place veterans at risk and impede recovery. This recommendation remains open pending further VA action. Diagnostic coding discrepancies further complicate VA’s ability to know if veterans with MDD are receiving care consistent with the CPG. Specifically, we found that for 11 of the 30 veterans’ medical records we reviewed the clinician coded the encounter as “depression not otherwise specified,” a less specific code than MDD, even though the clinician documented a diagnosis of MDD in the veteran’s medical record. Therefore, VA’s data may not fully reflect the extent to which veterans have MDD due to a lack of diagnostic coding precision by clinicians, or As a the extent to which such discrepancies may permeate VA data. result, VA’s ability to monitor veterans with MDD and assess its performance in treating veterans as recommended in the MDD CPG and measuring health outcomes for veterans is further limited because VA may not be fully aware of the population of veterans with MDD. VA’s data on the number of veterans with MDD are based on the diagnostic codes associated with patient encounters. To address this shortcoming, our report recommended that VA (1) identify the extent to which there is imprecise diagnostic coding of MDD by examining encounters with a diagnostic code of “depression not otherwise specified” and (2) determine and address the factor(s) contributing to imprecise coding. VA concurred with our recommendations and stated that they would examine patterns of diagnostic coding among veterans with new episodes of depression by evaluating diagnosis patterns and treatment settings, as well as conduct chart reviews for a sample of veterans to examine the diagnosis in the veteran’s medical record and the diagnostic code used for the encounter. VA’s review of the accuracy of diagnostic codes is ongoing. Additionally, during the course of our review, VA Central Office officials reported that they had discovered a software mapping error in VA’s medical record system where selection of MDD as a diagnosis when using a keyword search function may mistakenly result in the selection of the “depression not otherwise specified” diagnostic code. While this error has been resolved, according to VA officials the solution would only apply to encounters going forward and would not retroactively correct any previous coding discrepancies. As a result, any such instances would still be coded in VA’s system as “depression not otherwise specified,” even though these veterans were diagnosed with MDD, and therefore data VA collected prior to resolving the software error may still not fully reflect the number of veterans with MDD. Our recent work has 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 (BHAP templates)—a mechanism by which VA Central Office collects veteran suicide data from VAMCs’ review of veterans’ medical records. We found that over half of the 63 BHAP templates we examined had incomplete or inaccurate information (see fig. 1). It is important that VA have complete, accurate, and consistent data because VA Central Office uses this information to compile internal reports as part of VA’s quality improvement efforts for its suicide prevention program, and unreliable data limits VA Central Office’s ability to develop policy and procedures aimed at preventing veteran deaths. VA Central Office used veteran enrollment information when compiling the BHAP report in March 2014. Specifically, VA Central Office included clinical data in the BHAP report only for veterans utilizing VA services. However, we found that clinical data for 23 of the 63 BHAP templates we reviewed would not be included in the report because of missing data, such as not indicating whether the veteran was enrolled in VA health care services, even though the veteran had a VA medical record. Additionally, 40 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. These missing fields are counted as “no” in the report, meaning that the veteran did not have these symptoms.