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GAO report faults VA suicide data, tracking of veterans at risk

By MARK BRUNSWICK | (Minneapolis) Star Tribune (Tribune News Agency) | Published: January 6, 2015

Despite heightened awareness of military suicides, the Department of Veterans Affairs is incorrectly reporting suicide data and does a poor job of tracking and caring for vets at risk who are prescribed antidepressants, according to a report by the U.S. Government Accountability Office.

The VA's protocols for treating veterans diagnosed with depression were broken, and patient and suicide data were flawed, inconsistent and incomplete, the GAO report found.

Ten percent of veterans who received VA health care in the past five years were diagnosed with major depressive disorder, and 94 percent of those were prescribed antidepressants.

Because of problems that may permeate its record-keeping, the VA may understate the prevalence of major depressive disorders among veterans being treated at the VA.

Investigators reviewed 30 medical files for veterans prescribed antidepressants following a major depression diagnosis at VA medical centers in Phoenix; Philadelphia; Canandaigua, N.Y.; Gainesville, Fla.; Iowa City, Iowa; and Reno, Nev., from 2009 through 2013.

Twenty-six of those veterans weren't assessed after four to six weeks, the time specified in the VA's clinical practice guidelines, and 10 veterans did not receive follow-up care within the time frame recommended, the audit found.

The accuracy of veteran suicide data used for prevention work also was cited as "not always complete, accurate, or consistent," the report found.

Forty out of 63 Behavioral Health Autopsy Program reports had incomplete data, six had incorrect dates of death and nine reported an incorrect number of outpatient mental health visits in the last 30 days.

The errors were attributed to varying interpretations of the guidance given for filling out forms, which also were not generally reviewed at any level in the VA.

In response to the report, the VA said it will review its diagnostic patterns looking at depression and said it will ask for additional reviews of any suicide data it submits to ensure it is complete and current.

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The Phoenix VA Health Care System's main campus.
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