Preventing Suicide among Veterans

Posted on September 08, 2015
An estimated 18 to 22 veterans die by suicide every day, according to the Department of Veterans Affairs. That's almost one veteran every hour. For National Suicide Prevention Month, we’re taking a closer look at VA efforts to prevent veteran suicides. Reaching those in need To reduce veteran suicides, VA has taken a number of actions in the past decade, including monitoring veterans at high risk for suicide, creating a Center of Excellence for Suicide Prevention, and establishing the Veterans Crisis Line. If you or someone you know is a veteran or servicemember in crisis, call 1-800-273-8255 and press 1, reach out in an online chat, or send a text to 838255. Medicating for major depression In 2013, VA estimated that about 1.5 million veterans required mental health care, including for major depressive disorder, a condition that can increase the risk for suicide. Among veterans treated by VA between fiscal years 2009 and 2013, about 10% had major depressive disorder, and nearly all of those veterans were prescribed at least one antidepressant. Yet VA doesn’t know the extent to which veterans prescribed antidepressants are receiving recommended care for their depression. When we reviewed 30 veterans' medical records and compared their antidepressant treatment to VA’s own clinical guidelines for major depressive disorder, we found
  • 26 veterans weren’t assessed using a standardized tool 4-6 weeks after starting treatment, as recommended, and
  • 10 veterans didn’t receive follow-up care within the recommended timeframe.
Improving services for those who served To help inform and improve its suicide prevention activities, VA started collecting data about veterans who died by suicide, reviewing their medical records, and interviewing their families. This initiative is called the Behavioral Health Autopsy Program. However, we found that BHAP data related to past veteran suicides were not always reliable. Of 63 records we reviewed, 40 were incomplete. Among the missing information was whether the veteran had accessed VA health care services before his or her death. Other records had inaccurate data, like the wrong date of death or the wrong number of VA mental health visits.

GAO-15-55(Excerpted from GAO-15-55)

We also found that VA’s guidance for completing the BHAP forms was unclear. Additionally, no one at VA was routinely reviewing the suicide data for accuracy, completeness, or consistency. Missing or incomplete information about veteran suicides means VA can’t learn from those tragedies and incorporate lessons into its prevention efforts—the reason behind collecting the data. We reported our findings at a recent hearing on the risk of veteran suicide held by the House Veterans’ Affairs Subcommittee on Oversight and Investigations. We also made half a dozen recommendations to VA—one of which VA has already fully implemented. We are continuing to monitor the effectiveness of these and other VA efforts to prevent veteran suicides.