MDD is characterized by the presence of depressed mood or  loss of interest or pleasure along with other symptoms for a period of at  least 2 weeks that represent a change in previous functioning. The MDD CPG  includes approximately 200 recommendations to provide information and  assist in decision making for clinicians who provide care for adults with  MDD.assessments of depressive symptoms, such as the nine item Patient  Health Questionnaire (PHQ-9), should be used at the initial assessment  of MDD symptoms, to monitor treatment response at 4-6 weeks after  initiation of treatment, after each change in treatment, and periodically   For example, the CPG recommends that standardized  thereafter until full remission is achieved.assessment is effective 4-6 weeks after initiation of treatment, making  timely follow-up visits an important part of clinicians’ ability to assess  whether the current treatment plan is effective or should be modified. VA Data Show That 10 Percent of Veterans Had MDD and Most Were Prescribed at Least One Antidepressant, but VA Data May Underestimate MDD Prevalence

Data for fiscal years 2009 through 2013 show that about 10 percent of  veterans who received health care services through VA were diagnosed  with MDD, and of those, 94 percent were prescribed an antidepressant. VA’s Data May Not Fully Reflect the Extent to Which Veterans Have MDD Due to a Lack of Diagnostic Coding Precision by Clinicians

Based on our review of the documentation in 30 veterans’ medical  records from VA’s medical record system, we found that over one-third  (11) had diagnostic coding discrepancies. Additionally, 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 VA Central Office has not developed mechanisms to determine  the extent to which mental health care delivery conforms to the  recommendations in the MDD CPG. VA  policy states that antidepressant treatment must be consistent with VA’s  current, evidence-based CPG. Through our review of 30 medical records from the six VAMCs we  selected, we found examples of deviations from the CPG  recommendations for almost all veterans in our review.depicts the specific recommendations we reviewed and the number of  veterans that did not receive care consistent with the corresponding CPG  recommendation. Demographic and Clinical Data VA Collects on Veteran Suicides Were Not Always Complete or Accurate, and VAMCs Applied Instructions for Gathering Suicide Data Differently

We 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— a mechanism by which VA Central Office collects veteran suicide data  from VAMCs’ review of veterans’ medical records. Moreover, VAMCs interpreted and applied instructions for completing the  BHAP templates differently. Incomplete data limits  VA Central Office’s ability to identify information that can be used to help  VA Central Office develop policy and procedures to prevent veteran  deaths. Incorrect date of death: Six BHAP templates included a date of  death that was incorrect based on information in the veteran’s medical  record. This veteran would be included  in the BHAP interim report as having a mental health visit, and, as a  result, VA’s data would include an inaccurate count of the number of  veterans with mental health visits in the last 30 days.accurate information, VA cannot use this information to determine  whether policies or procedures need to be changed to ensure that   Without  veterans at high risk for suicide are being seen more frequently by a  mental health provider to help prevent suicides in the future. VAMCs, VISNs, and VA Central Office Do Not Review Suicide Data

We found that BHAP templates are not being reviewed by VA officials at  any level for accuracy, completeness, and consistency. Additionally, VA does not have mechanisms in  place to ensure that the Department is able to identify deviations from  CPG-recommended care and remedy those that could impede veterans’  recovery. To improve VA’s efforts to inform its suicide prevention activities, VA  should 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,  clarify guidance on how to complete BHAP templates to ensure that  VAMCs are submitting consistent data on veteran suicides, and  implement processes to review data on veteran suicides submitted by  VAMCs for accuracy and completeness. Characteristics of veterans diagnosed with MDD. VA’s Oversight of the Extent to Which Veterans with MDD Prescribed Antidepressants Are Receiving Care As Recommended in the CPG

To examine the extent to which VAMCs are providing care to veterans  with MDD who are prescribed antidepressants as recommended in the  CPG, we reviewed relevant VA policy documents. Information VA Requires VAMCs to Collect on Veteran Suicides

To analyze the information VA requires VAMCs to collect on veteran  suicides, we first reviewed VA policies, guidance, and documents related  to VA’s suicide prevention efforts to identify the mechanisms by which VA  collects veteran suicide data from VAMCs.
Why GAO Did This Study

In 2013, VA estimated that about 1.5 million veterans required mental health care, including services for MDD. MDD is a debilitating mental illness related to reduced quality of life and productivity, and increased risk for suicide. VA also plays a role in suicide prevention. GAO was asked to review how VA tracks veterans prescribed antidepressants and what suicide data VA uses in its prevention efforts.
This report examines (1) VA's data on veterans with MDD, including those prescribed an antidepressant; (2) the extent that veterans with MDD who are prescribed antidepressants receive recommended care and the extent to which VA monitors such care; and (3) the quality of data VA requires VAMCs to collect on veteran suicides. GAO analyzed VA data, interviewed VA officials, and conducted site visits to six VAMCs selected based on geography and population served. From each of these six VAMCs, GAO also reviewed five randomly selected medical records 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 but provide insights.

What GAO Found

GAO's analysis of Department of Veterans Affairs (VA) data for fiscal years 2009 through 2013 shows that about 10 percent of veterans who received VA health care services were diagnosed with major depressive disorder (MDD). MDD is characterized by depressed mood or loss of interest along with other symptoms for 2 weeks or more that represent a change in the way individuals function from their previous behaviors. Because GAO found diagnostic coding discrepancies in 11 of the 30 veterans' medical records it reviewed from six VA medical centers (VAMC), VA's data may understate the prevalence of MDD among veterans being treated through VA, to the extent that such discrepancies may permeate VA's data. One treatment for MDD is the use of medications such as antidepressants. According to GAO's analysis, 94 percent of veterans diagnosed with MDD were prescribed at least one antidepressant.
VA policy states that antidepressant treatment must be consistent with VA's current clinical practice guideline (CPG); however, GAO's review of 30 veterans' medical records identified deviations from selected MDD CPG recommendations for most veterans reviewed. For example, 26 of the 30 veterans were not assessed using a standardized assessment tool at 4 to 6 weeks after initiation of treatment, as recommended in the CPG. Additionally, 10 veterans did not receive follow up within the time frame recommended in the CPG. GAO found that VA does not have a system-wide process in place to identify and fully assess whether the care provided is consistent with the CPG. As a result, 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.
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 and procedures to help prevent future suicides. The BHAP templates are a mechanism by which VA collects suicide data from VAMC's review of veteran medical records. GAO's review of 63 BHAP templates at five VAMCs found that 40 of the templates that VAMCs submitted to VA Central Office had incomplete data. Also, GAO found that the BHAP templates VAMCs submitted contained inaccurate data. For example, 6 BHAP templates included a date of death that was incorrect based on information in the veteran's medical record, and 9 BHAP templates included an incorrect number of outpatient VA mental health visits in the last 30 days. Moreover, GAO found that VAMCs submitted inconsistent information because they interpreted VA's guidance on completing the BHAP templates differently. This situation was further exacerbated because BHAP templates prepared by VAMCs are generally not being reviewed at any level within the Department for completeness, accuracy, and consistency. Lack of complete, accurate, and consistent data and poor oversight can inhibit VA's ability to identify, evaluate, and improve ways to better inform its suicide prevention efforts.

What GAO Recommends

GAO recommends that VA identify and address MDD coding discrepancies; implement processes to review data and assess deviations from recommended care; and implement processes to improve completeness, accuracy, and consistency of veteran suicide data. VA concurred with GAO's recommendations and described its plans to implement them.