This report, however, focuses on activities of the Veterans Health Administration (VHA) within the Department of Veterans Affairs (VA). Both the National Strategy for Suicide Prevention and the VHA's approach to suicide prevention are based on a public health framework. As illustrated in Figure 1 , the framework has three major components: (1) surveillance, (2) risk and protective factors, and (3) prevention interventions. Data collected in surveillance can be used to identify risk factors (i.e., characteristics associated with higher suicide risk) and protective factors (i.e., characteristics associated with lower suicide risk). VHA Suicide Surveillance

No nationwide surveillance system exists for suicide among all veterans. Surveillance, or systematic collection of data on completed (i.e., fatal) suicides, is essential to define the scope of the problem (i.e., the suicide rate among veterans), to identify characteristics associated with higher or lower risk of suicide, and to track changes in the suicide rate and evaluate suicide prevention interventions. The VHA collects detailed information about suicides (and suicide attempts) among veterans that are known to VHA facilities through the Behavioral Health Autopsy Program (BHAP), which will eventually collect information in four phases. The VA is working with the DOD to identify suicides among all veterans, including those who do not interact with the VA. 
Information about deaths—including whether a death resulted from intentional self-harm (i.e., suicide)—is collected in death certificates by state, territorial, and local governments. The Centers for Disease Control and Prevention (CDC) aggregates death certificate data into the National Death Index (NDI), which can then be combined with data about who is a veteran. Identifying risk and protective factors is essential in order to design effective interventions aimed at lowering overall risk of suicide by reducing risk factors and/or increasing protective factors. Knowing what the risk factors are also helps in identifying at-risk groups or individuals so that interventions can be delivered to the people who need them most. Within the VHA, research on suicide risk and protective factors is supported by three research components: the Office of Research and Development (ORD), a Center of Excellence (COE) in suicide prevention, and a Mental Illness Research, Education, and Clinical Center (MIRECC) on suicide prevention. Potential Issues for Congress

The VHA has received both praise and criticism for its suicide prevention efforts and mental health services more generally. A 2010 progress report on an earlier version (2001) of the National Strategy for Suicide Prevention praises VHA's suicide prevention practices and recommends disseminating them to the rest of the health care system, describing the VHA as "one of the most vibrant forces in the U.S. suicide prevention movement, implementing multiple levels of innovation and state of the art interventions, backed up by a robust evaluation and research capacity." In contrast, some congressional testimony has criticized VHA's suicide prevention efforts for inadequacies, such as barriers to accessing care and lack of evidence-based treatments for those who do access care. A 2011 evaluation of VHA mental health services captures both sides of the argument, finding that VHA mental health care is generally at least as good as that of other health care systems, but that it "often does not meet implicit VA expectations." Potential issues for Congress and related recommendations by outside organizations fall into three categories: improving the timeliness and accuracy of surveillance data, building the evidence base, and increasing access to evidence-based mental health care. Appendix.
This report focuses on suicide prevention activities of the Veterans Health Administration (VHA) within the Department of Veterans Affairs (VA). The VHA's approach to suicide prevention is based on a public health framework, which has three major components: (1) surveillance, (2) risk and protective factors, and (3) interventions.
Surveillance, or systematic collection of data on completed (i.e., fatal) suicides, is essential to define the scope of the problem (i.e., the suicide rate among veterans), identify characteristics associated with higher or lower risk of suicide, and track changes in the suicide rate. No nationwide surveillance system exists for suicide among all veterans. Information about deaths (including suicides) is collected in death certificates by state, territorial, and local governments. Death certificate data are aggregated into the National Death Index, which can be combined with data about who is a veteran to identify veteran suicides. The VHA collects detailed information about suicides among veterans that are known to VHA facilities; however, the majority of veterans are not enrolled in VHA health care, so other sources of information (e.g., Department of Defense data) are necessary to identify veterans.
Information collected in surveillance is used to identify suicide risk factors (i.e., characteristics associated with higher rates of suicide) and protective factors (i.e., characteristics associated with lower rates of suicide). This is essential in order to design interventions that reduce risk factors and/or increase protective factors, thus lowering overall risk of suicide. Risk factors are also helpful in identifying at-risk groups or individuals so that interventions can be delivered to the people who need them most. Within the VHA, this research is supported by the Office of Research and Development; a Center of Excellence in suicide prevention; and a Mental Illness Research, Education, and Clinical Center on suicide prevention.
The intervention cycle includes three stages: (1) design and test interventions, (2) implement interventions, and (3) evaluate interventions. The research components mentioned above have roles in small-scale pilot testing and large-scale evaluations of interventions. VHA suicide prevention interventions include easy access to care, screening and treatment, suicide prevention coordinators, suicide hotline, education and outreach, and limited access to lethal means.
The VHA has received both praise and criticism for its suicide prevention efforts and mental health services more generally. A 2010 progress report on the National Strategy for Suicide Prevention describes the VHA as "one of the most vibrant forces in the U.S. suicide prevention movement, implementing multiple levels of innovation and state of the art interventions, backed up by a robust evaluation and research capacity." In contrast, some have testified before Congress that VHA's suicide prevention efforts have inadequacies, such as barriers to accessing care and lack of evidence-based treatments for those who do access care. A 2011 evaluation of VHA mental health services captures both sides of the argument, finding that VHA mental health care is generally at least as good as that of other health care systems, but that it "often does not meet implicit VA expectations." An independent evaluation of VA mental health services is underway.
Potential issues for Congress and related recommendations by outside organizations fall into three categories: improving the timeliness and accuracy of surveillance data, building the evidence base, and increasing access to evidence-based mental health care. Public laws addressing suicide prevention among veterans are described in the Appendix.