GAO VA Suicide Report

Benjamin KrauseThis week, GAO revealed VA is failing to accurately use its veteran suicide protocol to help the agency respond to the staggering number of suicides. This is par for the course for many whistleblowers calling out VA for neglecting suicidal veterans.

Folks like Brandon Coleman have been proclaiming for some time that VA is flatly failing its suicidal veterans. The Veterans For Common Sense lawsuit apparently failed to accomplish the long range goal of encouraging greater responsiveness to the needs of veterans suffering from PTSD and related suicide. I guess we know what direction VA took in response to the greater public scrutiny from whistleblowers and that lawsuit…

Yeah, VA extended its middle finger and said, “If you don’t like it, sue me… Oh wait, you can’t according to the 9th Circuit or anywhere else.”

The new report summarizes its findings as follows:

Scathing GAO Audit Summary Of VA Suicide Policy

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.

Source: http://www.gao.gov/products/GAO-15-648T

33 COMMENTS

  1. Seems like “Muppet Labs” has more accountability and protocol than the VA…the further really sad thing is this is not the first time the GAO has found fault with the VA’s handling of Veteran Suicides and Mental Health and following-up with their patients…and one must wonder if this huge fail has been systemic going back to Vietnam War Days or even earlier?
    I know they just keep throwing darts at my brother with various different antidepressants, all mostly very old school drugs on their Formulary, and what many people may not realize is the fact that MANY antidepressants *can* cause hyper-manic states and worse…and with the VA not following-up in so many weeks it’s no wonder my poor brother has gone so many years with no relief and the VA never follows-up with him in due time and when he says more times than not, he will go to an appointment after a good drive only to find out they rescheduled him months into future without even notifying him…I am betting this is happening to many other Veterans as well.
    How then can the VA decide to discontinue a “Suicide Prevention Program” in lieu of some online program? Was it the simple fact the VA “got caught” not giving great care so they thought thy could just farm people out to the DOD program or whatever this online program is instead?
    Was it more insidious? Was the VA trying to again divert funds for ‘something else’, at the very expense of Veteran’s lives?
    We probably would all be more safe with Haitian Witch Doctors than the Last In Their Class VA Witch Doctors.

  2. I would like to know, When will something happen to “shake up” the VA? With all the negative press it receives, something has got to give. Veterans deserve better medical care than what their receiving today.
    How much longer will it take for the upper crust of the VA to realize they can’t continue to treat veterans/patients in this manner?
    Sooner or later, they must be held accountable. I pray it’s not later!!!!

  3. I have come to the conclusion that blogs, forums news reports, reports in general are good for the exposure of problems that have existed and will continue to, if we as a people do not utilize the proper tools to effect change. In a legal scenario, that would be filing injunctions, sanctions and amicus curiae briefings in court. If all of our resources can somehow come together, such as organizing through the State bar, pro bono services, that would give new laywers earned hours in this project to effect change in making and forcing the Congress and the Execitive Branch to do something. Specifically rejecting the claim of immunity from lawsuits, because it contradicts the Declaration of Independence and our government is not of Sovereign authority, because we broke away from England a long time ago. Forcing veterans to pay for healthcare for money that has been already taxed is a form of taxationwithout representation and conflicts with the US Tax Code. Let’s call it the Veteran’s Representative Pro Bono Project VRPB

    • I agree some how a group needs to be formed and monies collected to help pay the pro bono lawyer travel, etc. Maybe I’m wrong but something and someone’s needs to help, all of our veterans stories or facts can’t all be wrong about the way the va is treating us. Doing so with out having to worry about anything being done to them for their failure to assist veterans

  4. Fox 35 news “Pentagon spending $9 million a day to fight ISIS.”
    Maybe this is where all that VA money is going. The way I see it is, this war has to be paid for somehow. What better way than to cut expenditures from other necessary programs, ie; VA, Social Security, Workers Comp., Medicare and many other federally funded programs. That’s my opinion, folks!
    According to Congresswoman Roby, the Army is NOT being allowed to use their helicopters. She has a new video is on UTUBE, the title is, “Rep. Roby Floor Speech on FY ’16 Defense Appropriations Bill”. It was put on UTUBE June 11, 2015…
    Check it out….

  5. Is it true that you can’t sue VA staffs for wrong doing? Like intentional or negligence infliction of emotional distress. Any idea?

    • The Tort Claims Act allows you to sue, but if you negate the acceptance of juriscdiction of the government citing Soveigner authority. Your jurisdiction statement should refer to “common law” and that under the Declaration Of Independence from Sovereign rule, your jurisdiction and venue should state so citing the 11th amendment where the government is not a body, but the individual who represented “The People” in its duty is the subject of controversy, in which you are entitled to a jury trial on demand. They hate these kind of claims.

      • Hey Doc, I swear I could spend days sharing “FUN FACTS!” Like did Bush and Cheney break an Amendment? Answer? YES THEY DID. XII AMENDMENT IS PRETTY CLEAR BUT KARL THE HAM ROVE ( John Stewart and Colbert, that was a classic!) BUT ALSO CHENEY PROFITED OF THAT WAR AND GEE BY PASSED THE CLEAN WATER ACT FOR FRACKING? SEND THE WATER TO HIM! JUST FYI-DONALD RUMSFELD MUST FEEL SOME GUILT IF HE CAME OUT OF THE CLOSET AND STATED WE NEVER SGOULD HAVE DONE WHAT WE DID-THAT MAKES THREE. THEY ARE WAR CRIMINALS, PLAIN AND SIMPLE! IF I DIDN’T SPELL HIS NAME RIGHT, DAMN IT MEANS I AM TOO HUMAN AND MAKE MISTAKES!!!
        ALSO KEEP IN MIND MY EYES DO NOT ALWAYS ADJUST, FIBROMYALGIA, SO BESIDES FOG, AND ADD SEVERE PAIN, THESE CAN AND DO HAVE AN EFFECT ON MEMORY. I DECIDED RECORD MY VOICE SO MAYBE IT COULD TRIGGER A MEMORY OF A CONVERSATION. WOW! I THINK MY FAMILY WAS UP ABOVE AND STATED, “B.S.! NOT THIS TIME SHE HAS ALWAYS DONE HER BEST, SERVICE TO OTHERS AND LYING YOU DO NOT DO!” DID I CALL ALL THOSE WHO BLEW UP MY PHONE? YUP. BUT, STEP BACK, I DECIDED BOW OUT GRACEFULLY, SPEAK KINDLY SO THAT WAY NO HARD FEELINGS. I WAS GOING TO SEEK TREATMENT MY WAY, MAY EVEN DUO IT WITH A PRIEST.
        I REALLY DO NOT SEE ANYTHING MORE THAN ACTORS WHO GET SWAYED BY LOBBYIST. THEY SPEAK BUT NOTHING REALLY COMES OUT. AS I GOT CONFRONTATIONAL WITH ONE OF MY OWN REGARDING BUSH! IT IS NEVER ABOUT RIGHT OR WRONG IT IS DOING YOUR RESEARCH. TO ME? IS IT PICKING THE LESSER OF TWO EVILS? YOU DECIDE!
        BUT DAMN DOC! I LIKE YOUR STYLE AND I KNOW WE COULD SHARE A WHOLE LOT OF STORIES! BLESSINGS AND KEEP TELLING IT LIKE IT IS! I SO ENJOY IT!!!

    • True… one, as far as has been reported, can not sue the Doctors, nurses, technicians etc. etc. When one files suit against the VA, it goes against the VA as a whole. This is why Doctors, nurses, technicians are transferred to other VA facilities. I know this is wrong. But that’s the way of the VA.
      Also, when a person(s) receives a settlement, the money is dispersed through somewhere, other than through the monies allocated to the VA for medical and administrative purposes.
      Of course, many voters and taxpayers are unaware of this! There is websites that have an abundance of info concerning the VA. One is; VAmalpractice.info. It gives MANY examples of what is NOT being done for the Veterans, what it does relay is what the VA does TO Veterans .
      Another site is DAVREFORM
      Returning the dav to the members. Their ‘comments section’ is filled with info about the VA. And how taxpayers are being ripped off….
      Keep searching the web. You will be amazed of how much negative publicity is out there!!!!!
      Happy hunting….

  6. The VA is all about studies, and the VAOIG is all about recommendations. This morning I started reading my email from the oldest, which was the post of this blog received at 2:33AM, a couple of emails up was the following email received at 10:07 AM this morning from VA News Releases – Office of Public and Intergovernmental Affairs. (Or, as I call them “The Office of Propaganda”). The Headline read: “Study may help Department of Veterans Affairs find patients with high-risk of suicide.” It can be found at this link:

    http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2710

    For God’s sake, maybe, just maybe, if they followed their own protocols and used some common sense the VA wouldn’t be trying to push back and have another wasted study on things we already know. Possibly, by hiring competent psychiatrists, psychologists and therapists it may also reduce the number of suicides?

    If 8,000 citizens were dying in plane crashes every year (the approximate number of veteran suicides), would there be a public outcry to get the problem fixed? It is now 11 AM where I am and since I had breakfast, 3 more of my brothers or sisters have taken their own life. The number of suicides for the US last year was about 40,000. Meaning one in five suicides, or 20% of all suicides are vets yet, we make up less than 6% of the population

    Having PTSD, I see a VA Psychiatrist every couple of months. I ask her questions regarding studies about PTSD and numerous secondary medical issues to PTSD, such as sleep apnea and unusual cortisol levels. (There are a number of published studies regarding these two issues and I have both medical conditions). Her response is invariably, “I have not heard of that.” She then will ask me, “Would you like to see me in two or three months?” My vet center counselor I can only see about once every month and half. He only talks about his gun collection, his nagging wife and where he is going on vacation for the hour I spend with him. I do not have suicidal or homicidal ideation. However, I can sure see where someone who does, will never get the help they need.

  7. It does appear from the G7 meeting that Global Warming,Educating our enemies,and being Muslim overshadowed the American Veterans current needs !!!

  8. OK…I get it…the VA is REALLY screwed…I’ve been hearing that drumbeat for years..The question is…WHAT CAN BE DONE ABOUT IT? (yes I’m yelling because I’m REALLY REALLY mad)…Scandal, lawsuits, congressional investigations, the VA just keeps rolling merrily along doing the same old stuff in the same old way…Does anyone know of ANYTHING that can be done that will be effective?

    • I honestly believe nothing will happen until millions of taxpayers, veterans and MANY, and I do mean MANY, converge upon Washington D.C. and let them know, in no uncertain terms, we are feed up with the way they are ruining this country! They need to know one thing: their jobs are on the line….. Do the job they get paid very handsomely to do. Or get the hell out, and let a real representative work out the details! No more lobbyists, large PAC’s (so officials can buy their way into office), etc. etc. etc.
      How much longer will the American Public put up with this nonsense?

  9. Maybe I’m wrong, but I always assumed SUICIDE was a TOP mission at the VA as the number one cost saver! RIP Veterans.

  10. I feel the root cause of PTSD IS the VA!!!!!! How many veterans are diagnosed with PTSD before they come home. How many veterans who committed suicide AFTER going to the VA???????????????????

      • Ever since I started to post to this forum the VA denied a claim and cut my current comp by 10% – no reason they just said there was a ‘serious error’ My VSO claims she has no idea why. Wanna bet!!!

  11. Guild lines the only guide lines they use and follow are the ones that will cover their own ass, they break guide lines every day and when the guide lines concerns veterans they are thrown out the! Window, they don’t have to accountable for anything they make their own rules and no one cares, as long as it does not effect them and their money. Other wise it’s a free for all. If they do something wrong they don’t have to worry, higher management will cover it up for them and then that employee owns that manager a favor, you wash my back and I’ll wash yourself. McDonald is no better, all for one and just one themselves.

  12. If we were living in the 1770’s, King George would be proud of our elected and appointed officials. It seems many are doing exactly what was written in our “Declaration of Independence”. Y’all remember, that little piece of parchment that spelled out our “grievances” of what Great Britain was committing against us!
    I might also add, when those men signed that ‘paper’, they were committing treason.
    The penalty, at that time, would have been: hanging, left to rot so all could see, disimboweled, then “Drawn and Quartered”.
    Just saying, folks!!!!

    • UM YIKES!!! WHAT I FIND VERY INTERESTING ABOUT THAT DOCUMENT ( YES, LOCKED AND LOAD WITH A POCKET SIZE BOOK-TOTALLY NERD OR AS I SAY, JUST ANOTHER INTELLECTUAL BADASS!
      YOU KNOW WHAT I FIND SO INTERESTING, I WAS IN A STORE I DESPISE BUT THEY CARRY A FEW ITEMS I HAVE NEEDED. I’VE BEEN POLITICALLY ACTIVE FOR YEARS. (MY SPEECH PROFESSOR SWORE HE KNEW ME DURING A TIME “AGAIN” WITH MY BACK, BETWEEN SURGEY TWO AND SUGERY THREE). THIS GUY WALKS UP, SEES MY OBAMA SHIRT AND HE MENTIONED THE WRONG WORDS-READY? “YEAH I JUST MOVED HERE FROM CALIFORNIA BECAUSE THE “WHOLE STATE IS ALL PRO LIBERAL!” OH BOY, WE NEED TO SCHOOL THIS ONE. I STATED, “REALLY? BECAUSE I AM FROM AN EXTREMELY CONSERVATIVE FAMILY, AND YES CHILDREN TEND TO FOLLOW THE PARENTS BELIEFS-NOT ME! BUT WHERE I LIVED? THAT WAS THE NORMAL FOR THAT CITY. HE STATED HE WAS WITH THE TEA (BAGGERS) CULT CLICK, “WE WOULD LIKE OUR ENSIGN BACK “PALIN IDIOT!” DON’T TREAD ON ME!”
      SO JUST FOR A TOPIC OF DISCUSSION OF WHY HE CHOSE THAT ( CULT ) PARTY? READY?
      “BECAUSE I BELIEVE LIFE, LIBERTY AND THE PRSUIT OF HAPPINESS.” YUP, THATS IT! I GOTTA BE ME! I ASKED HIM THAT QUOTE AND HOW ONE SHOULD APPLY IT IF THAT IS ALL HE COULD COME UP WITH, “DUDE, I AM THE ICE BERG AND YOUR SHIP IS SINKING PRETTY FAST!
      1. WELL, IF YOU BELIEVE IN LIFE, FOR OR AGAINST THE DEATH PENALTY? ( NO INTELLIGENCE WORTH WASTING SPACE) BUT WHEN I BROUGHT UP WOMEN AND THE OBVIOUS NEED FOR PLANNED PARENTHOOD AS WELL AS THEIR RIGHT AND THEIR BODIES NO EMPLOYER HAS THE “RIGHT TO DICTATE THEIR CHOICES.” OKAY HE IS GETTING CLOSER TO MY OBJECTIVE REGARDING THAT STUPID DEBATE, I EXPLAINED, “MY OWN DAUGHTER NEEDS THEM, AND SHE DEFINITELY SHOULD HAVE NO MORE OR SHE COULD DIE, 50/50, “NOT GREAT ODD’S , BUT WE ALL FACED SHE WAS IN THE DANGER ZONW AND YES GRANNY HERE, JUST LOVES BIG TIME! HE PROCEEDED THINGS? I “PRACTICE TO TELL ME HE BUYS nCONDOMS, CANT SHE GET THE IMPLANT OBVIOUSLY HE DID NOT UNDERSTAND MY RESPONSE. SIMPLE TEST!
      1. “Wait: , I BELIEVE TOLD YOU WHY, BUT MOVING ON THAT CAN STUMPL DO A DOW.N! THERE TWO STATES THARE WHICH ‘
      2. WHA MIRE TACKED P

      • You do know this forum is not about your personal political agenda? The comment you replied to in no way suggested a political stance. The vets on here, regardless of political persuasion, post useful respectful comments or suggestions. Calling people names, incoherent rants and capitalizing random words gets you no where. If this is all you have to offer – find a political forum where you can rant about your point of view. By the way this column was written months ago – we have all moved on.

      • Thank you DanF. Hats off to you! I’m still trying to ‘post’ the “Constitution” and “Bill of Rights” on here. I feel many Americans have lost the “WHY” America became the country it was meant to be. This is why I have, since i have began posting comments, put ‘Historical Information’ on this site. Maybe then, some might look up the information and become aware of what our “Elected” and “Appointed” officials are supposed to be doing in their ‘political positions’! And, if they get caught committing possible criminal acts, then, under the Laws of Our Nation be prosecuted!!!!

    • I agree with Crazyself about the punishment,but these people(and I use that title loosely)that are supposed to care for those who bore the Burden of War as Abraham Lincoln once said have sadly turned their backs on us and why wouldn’t they,it has no ill effect on them or their Families because they still get their 6 figure incomes,outrageous benefits ,unlimited paid sick leave and Tpo of the line unlimited medical care for them and their Families with no waiting for months or more waiting in limbo.So why should Congress and the Senate care about us just because we put our lives on the line so they can continue to lie!!

      I love America but if a Congressman or Senator was on fire I would not even P**S on them to put out the flames!!

      Semper Fi

      • Bob, thank you for agreeing with me. I wish I knew how to put the “Declaration of Independence” and the “U.S. Constitution”on here. It might help all who read them to get a better understanding of how we “became a free and independent nation”! For example, did you know Samuel Adams WAS, and IS concidered, the first “TRUE PATRIOT”. He was, and is, considered the Catalyst which started the “Civil War” between England and the Colonies! When any monies were ‘donated’ to the cause, he kept NONE of it. He was a member of the “Sons of Liberty”! Unlike John Hancock, who was despised by his fellow Bostonians, who had to lose everything, and I do mean everything, before becoming a “Patriot”! This is history. Our Continental Congress was made up of individuals, even though they had flawes,who understood the importance of “WHY” we had to be a nation all onto ourselves. The words that had been written in both documents, were carefully set down so that a “Government NOT by the people would not and would not exist”.
        I don’t know how much more I can explain the importance of why the people need to take back control of a Government, that in my opinion, has become corrupt.
        We see this just about every day. Where our elected and appointed officials do just about anything they please!
        I hope everyone looks up these two documents. They are who and what we are as a nation, as one of our Founding Fathers said!

      • Bob, on ‘soda head’ yesterday it was reported HUD, with permission from Obama, is changing their ‘rules’. They now want to build low-income housing in high-income areas around the country. How do you think that’s going to go over with the wealthy?
        “Obama set to force section 8 housing into wealthy neighborhoods for diversify”, is the title of the article.

  13. I put the “Declaration of Independence” on here. Somehow, it is gone? Why? I believe all peoples should read it, along with the “Constitution of the United States of America”. I also believe reading these ‘documents’ will empower the people with all their knowledge the ‘founding fathers’ gave us to govern a nation. Remember, it is by these documents that insures our freedoms!
    Anyone wish to reply????

  14. HEY GUYS? I WASN’T TRYING TO MAKE IT A POLITICAL FORMAT REGARDING THE TEA PERSON. WHAT I WAS TRYING TO MAKE HIM UNDERSTAND IS YOU NEED TO KNOW MORE THAN “ONE LINERS.” GENERALIZING OR STEREOTYPES OF A WHOLE STATE SOUNDS COMPLETELY OFF ( ARE THEY FOS STATES? HUMOR ALL! YES, BAD AT JOKES BUT I STILL TRY!). JUST FYI THOUGH, TWO. STATES HAVE LARGER STATE CONSTITUTIONS THAN THE COUNTRY. SORRY IT SEEMED TO SOUND POLITICAL, HEY A T-SHIRT I GRABBED IT WASN’T A LET ME GET ALL PERECTIONIST DAY. “WITH AGE COMES WISDOM, AND YOU LEARN WHAT IS IMPORTANT AND WHAT IS NOT.” SHOULD I STATE INTERESTING FACTS? MOST STUDENTS THAT DO POST-GRADUATE COURSES COME FROM INDIA AND CHINA. THAT COST FOR THOSE STUDENTS IS HIGHLY EXPENSIVE AND TESTING THAT THEY MUST DO IN THEIR OWN COUNTRY BEFORE GETTING ACCEPTED.
    “I CARE.”
    AND YES, MY PROGRAM HAS STATED THIS SITE AS HACKED!
    REMEMBER, I LIVE IN SEVERE PAIN. I HAVE A HIGH PAIN THRESHOLD. FIBROMYALGIA AND THE EYES ADJUSTING I CANNOT CONTROL. SO I AM NOT SHOUTING AT ANYONE, I AM ONLY TRYING TO MAKE SURE I SEE. OBVIOUSLY YOU SAW A DROP OFF, THAT WAS PAIN INTERUPTING ME AND THE “ADDED BONUS” OF MORE.
    BLESSINGS AND HAVE A GREAT WEEK! MAY EACH OF US BECOME STRONG AND CAN DO MORE THAN WHAT IS REALLY WRONG AND GET LISTENED TO, BECAUSE THOSE NUMBERS ARE NOT ALL, ONLY THE ONES REPORTED!!!

    • Sorry about your pain. I truly am. I live with it 24/7/365.
      These vets who post on here are Dems, Reps or of other groups. They have one thing in common. That is, being screwed by a government agency. They want it to be fixed. If it can’t be, then do the right thing, dismantle it and start again!
      I post “Historical Facts” because knowledge is power. The more knowledge a person has his or her power becomes stronger. Do you agree.
      Read the “Declaration”, “Constitution” and the “Bill of Rights”, then explain to me this, How many of our “Rights” have been trampled upon? Answer that one!

  15. Two thoughts – we sued because we were denied access to BVA (see our case HI US Dist Ct CV14-00547 LEK BMK Second Amended Complaint Doc 60 – just filed today so not on PACER YET). It demands that Beneficiary Travel send a Due Process notice for their reimbursement. Our current BT VA EFT deposit w/NO identifying paperwork leaves me wondering what they have paid and what I am waiting for.

    My guidance – BLESS MR. KRAUSE – say “forget the money just follow your own VA rules and the Fifth Amendment (Due Process of Law).”

    Our suit was dismissed when we claimed monetary damages, so now we are just asking for injunction for VA to place our claims into BVA (or pay up) and declaratory judgment for the BT paperwork with each payment.

    Second, I am equally horrified that the VA gets away with 8000 (or more) people dying on their watch – so to speak. The Post Office doesn’t lose 8000 of its customers a year by carelessness, or Dept of Ed or any other federal agency – except DOD. The military does lose a lot of their people each year which may inure the VA to its losses. You just get use to it and the VA is rife with inept former military who get promoted far beyond their ability. For a prime example, the Yukio Okutsu State Veterans’ Home in Hilo HI had to take out a front page ad in 6/24/2015 Hawaii Tribune-Herald to introduce the Home’s new administrator who replaced the capable non-veteran former administrator with a new guy they have to use tax dollars to “sell” to the Vets.

    Anyway, thanks to Mr. Krause for his great advice. For the first time, I have a glimmer of hope because they can’t say (per VCS precedent) that we are trying to evade the VJRA 38 USC.

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