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VA Health Care: Improvements Needed to the Monitoring of Antidepressant Use for Major Depressive Disorder and the Accuracy of Suicide Data

GAO-15-648T Published: Jun 10, 2015. Publicly Released: Jun 10, 2015.
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What GAO Found

Department of Veterans Affairs (VA) policy states that antidepressant treatment must be consistent with VA's current clinical practice guideline (CPG) for major depressive disorder (MDD); however, GAO's recent review of 30 veterans' medical records found that most contained deviations. For example, although the CPG recommends that veterans' depressive symptoms be assessed at 4-6 weeks after initiation of antidepressant treatment using a standardized assessment tool, 26 of the 30 veterans were not assessed in this manner within this time frame. Additionally, 10 veterans did not receive follow up within the time frame recommended in the CPG. GAO found that VA (1) does not have a system-wide process in place to identify and fully assess the extent to which veterans with MDD who have been prescribed antidepressants are receiving care as recommended in the CPG and (2) does not know whether appropriate actions are being taken by VA medical centers (VAMC) to mitigate potentially significant risks to veterans. GAO also found that VA's data may underestimate the prevalence of MDD among veterans being treated through VA as a result of imprecise coding by clinicians, further complicating VA's ability to know if veterans with MDD are receiving care consistent with the CPG.

GAO's recent work has found that 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 to help prevent future suicides. The BHAP templates are a mechanism by which VA collects suicide data from VAMCs' review of veteran medical records. GAO's review of the 63 completed BHAP templates at five VAMCs found that (1) over half of the templates that VAMCs submitted to VA had incomplete or inaccurate data, and (2) VAMCs submitted inconsistent information because they interpreted VA's guidance differently. Lack of complete, accurate, and consistent data—coupled with GAO's finding of poor oversight of the review of BHAP templates—can inhibit VA's ability to identify, evaluate, and improve ways to better inform its suicide prevention efforts.

Number of Behavioral Health Autopsy Program (BHAP) Post-Mortem Chart Analysis Templates with Incomplete or Inaccurate Data

Number of Behavioral Health Autopsy Program (BHAP) Post-Mortem Chart Analysis Templates with Incomplete or Inaccurate Data

Why GAO Did This Study

In 2013, VA estimated that about 1.5 million veterans required mental health care, including for MDD. MDD is a debilitating mental illness related to reduced quality of life and increased risk for suicide. VA also plays a role in suicide risk assessment and prevention.

This testimony addresses the extent to which (1) veterans with MDD who are prescribed an antidepressant receive recommended care and (2) VAMCs are collecting information on veteran suicides as required by VA. The testimony is based on GAO's November 2014 report, VA Health Care: Improvements Needed in Monitoring Antidepressant Use for Major Depressive Disorder and in Increasing Accuracy of Suicide Data (GAO-15-55). For that report GAO analyzed VA data, interviewed VA officials, and conducted site visits to six VAMCs selected based on geography and population served. GAO also reviewed randomly selected medical records for five veterans from each of the six VAMCs, 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. GAO followed up in May 2015 to determine the status of GAO's previous recommendations.


GAO recommended that VA implement processes to assess deviations from recommended care; identify and address MDD coding issues; and implement processes to improve veteran suicide data. VA has made progress on these recommendations and has fully implemented one.

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AntidepressantsData collectionDisease detection or diagnosisEvidence-based practicesHealth care programsHealth care servicesInternal controlsMedical recordsMental illnessesMonitoringPatient care servicesQuality of lifeRisk assessmentSuicideSuicide preventionVeteransVeterans benefitsVeterans hospitals