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. 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. Veterans in Our Review Often Did Not Receive Recommended Care, and VA Lacks Methods to Track Whether Recommended Care Is Provided

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. 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. Diagnostic coding discrepancies further complicate VA’s ability to know if  veterans with MDD are receiving care consistent with the CPG. 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 review of the  accuracy of diagnostic codes is ongoing. Data VA Collects on Veteran Suicides Were Not Always Complete, Accurate, or Consistent

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. For example, we found 6 BHAP templates that  included a date of death that was incorrect based on information in the  veteran’s medical record. We also found several situations where VAMCs interpreted and applied  instructions for completing the BHAP templates differently, resulting in  inconsistent data being reported across VAMCs. To improve VA’s efforts to inform its suicide prevention activities, we  made three recommendations in our November 2014 report that directed  VA to (1) clarify guidance on how to complete the BHAP templates to  ensure that VAMCs are submitting consistent data on veteran suicides,  (2) ensure that VAMCs have a process in place to review data on veteran  suicides for completeness, accuracy, and consistency before the data are  submitted to VA Central Office, and (3) implement processes to review  data on veteran suicides submitted by VAMCs for accuracy and  completeness.
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.

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.

What GAO Recommends

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.