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Health Care for Veterans: Suicide Prevention
Erin Bagalman
Analyst in Health Policy
March 19, 2015
Congressional Research Service
7-5700
www.crs.gov
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Summary
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.
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Contents
A Public Health Framework for Suicide Prevention ........................................................................ 1
VHA Suicide Surveillance ............................................................................................................... 2
VHA Research into Risk and Protective Factors ............................................................................. 3
VHA Office of Research and Development (ORD) .................................................................. 5
Center of Excellence (COE) ...................................................................................................... 5
Mental Illness Research, Education, and Clinical Center (MIRECC) ....................................... 6
Selected VHA Suicide Prevention Interventions ............................................................................. 6
Easy Access to Care ................................................................................................................... 7
Screening, Assessment, and Follow-Up .................................................................................... 8
Treatment of Mental Illness ....................................................................................................... 8
Suicide Prevention Coordinators ............................................................................................... 9
Suicide Hotline ........................................................................................................................ 10
Education and Awareness ........................................................................................................ 10
Limited Access to Lethal Means ............................................................................................. 11
Potential Issues for Congress ......................................................................................................... 11
Improving the Timeliness and Accuracy of Surveillance Data ............................................... 12
Building the Evidence Base ..................................................................................................... 13
Increasing Access to High-Quality Mental Health Care .......................................................... 13
Figures
Figure 1. A Public Health Framework for Suicide Prevention ........................................................ 2
Tables
Table 1. Selected Risk and Protective Factors in the General Population ....................................... 4
Appendixes
Appendix. Public Laws Addressing VHA Suicide Prevention Efforts .......................................... 16
Contacts
Author Contact Information........................................................................................................... 18
Acknowledgments ......................................................................................................................... 18
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ongress has attempted to address the problem of suicide among veterans through
legislation1 and oversight hearings,2 both on prevention of veteran suicide specifically and
C on veteran mental health more broadly. A task as challenging as preventing suicide
requires collaboration among federal agencies, state and local governments, other organizations,
communities, and individuals. This report, however, focuses on activities of the Veterans Health
Administration (VHA) within the Department of Veterans Affairs (VA). The VHA’s approach to
suicide prevention is based in part on the National Strategy for Suicide Prevention,3 which
involves multiple federal departments, including the VA, Defense (DOD), and Education (ED), as
well as several agencies within Health and Human Services (HHS).4 While this CRS report
focuses on suicide prevention efforts of the VHA, activities of other entities are discussed as they
relate to VHA activities.
This CRS report begins with a brief overview of the public health framework for suicide
prevention, which forms the basis for both the National Strategy for Suicide Prevention and the
VHA’s approach to suicide prevention. The three subsequent parts of the report correspond to the
three major components of the public health framework: (1) suicide surveillance, (2) suicide risk
factors and protective factors, and (3) suicide prevention interventions. The final section
addresses potential issues for Congress, and the Appendix summarizes provisions of public laws
addressing suicide prevention among veterans.
A Public Health Framework for Suicide Prevention
Prevention of suicide can be approached in two ways, which are not mutually exclusive. The
public health approach intervenes with populations (e.g., distributing educational materials about
mental illness and mental health services), whereas the clinical approach intervenes with
individuals (e.g., prescribing antidepressant medication to a person diagnosed with depression).
The individual focus of the clinical approach limits its reach to those who access the health care
system;5 clinical interventions are necessary but not sufficient. The population-based public
health approach is considered essential to address the broader problem of suicide among all
veterans, including those who may not currently be in contact with the health care system.
1 See the Appendix for public laws addressing suicide among veterans.
2 See, for example, U.S. Congress, Senate Committee on Veterans’ Affairs, VA Mental Health Care: Ensuring Timely
Access to High-Quality Care, 113th Cong., 1st sess., March 20, 2013; U.S. Congress, House Committee on Veterans’
Affairs, Subcommittee on Health, Service Should Not Lead to Suicide: Access to VA’s Mental Health Care, 113th
Cong., 2nd sess., July 10, 2014; and U.S. Congress, Senate Committee on Veterans’ Affairs, Mental Health and Suicide
Among Veterans, 113th Cong., 2nd sess., November 19, 2014.
3 U.S. Department of Health and Human Services (HHS) Office of the Surgeon General and National Action Alliance
for Suicide Prevention, 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action, Washington
DC: HHS, September 2012, http://www.surgeongeneral.gov/library/reports/national-strategy-suicide-prevention;
hereinafter referred to as National Strategy for Suicide Prevention.
4 Federal Working Group on Suicide Prevention, National Strategy for Suicide Prevention: Compendium of Federal
Activities, 2009. HHS agencies involved in suicide prevention include the Centers for Disease Control and Prevention
(CDC), Indian Health Service (IHS), National Institute of Mental Health (NIMH), Substance Abuse and Mental Health
Services Administration (SAMHSA), Health Resources and Services Administration (HRSA), Agency for Healthcare
Research and Quality (AHRQ), and Administration on Aging (AoA).
5 This report focuses on the public health approach. A full discussion of the clinical approach to suicide prevention is
beyond the scope of this report. The pharmacotherapy and psychotherapy mentioned in the “Screening, Assessment,
and Follow-Up” section are examples of the clinical approach.
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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.
Suicide surveillance involves collecting data on completed (i.e., fatal) suicides in order to define
the scope of the problem. 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). Suicide prevention interventions aim to reduce risk factors
and/or enhance protective factors that have been identified; interventions may target high-risk
groups or individuals, identified based on known risk factors.
Figure 1. A Public Health Framework for Suicide Prevention
Source: CRS analysis of major components of U.S. Department of Health and Human Services (HHS) Office of
the Surgeon General and National Action Alliance for Suicide Prevention, 2012 National Strategy for Suicide
Prevention: Goals and Objectives for Action, Washington DC: HHS, September 2012.
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. In order to evaluate interventions, suicide surveillance must measure the
same thing, in the same way, repeatedly over time. In the case of veteran suicide, surveillance
requires identifying both who is a veteran and who has died by suicide.
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 VHA has already implemented the two phases:
standardized chart reviews and interviews with family members. The third and fourth phases
involve interviewing the last clinician to see the veteran and locating public records that might
indicate stressors (e.g., bankruptcy or divorce). A Government Accountability Office (GAO)
evaluation found that some BHAP reports were not submitted, some included inaccurate
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information, and some were incomplete. VHA facilities had interpreted BHAP instructions
differently, and no officials were reviewing BHAP reports for accuracy or completeness.6
Resolving the problems the GAO identified with BHAP would result in better information about
suicides among veterans that are known to VHA facilities; however, information collected solely
by the VHA would still exclude suicides among other veterans (i.e., those who are not known to
the VHA). Of more than 21 million veterans estimated to live in the United States, fewer than 10
million are enrolled to receive health care from the VHA.7 The VA also has records of veterans
who receive other benefits (e.g., home loans), regardless of whether they are enrolled in VHA
health care, but does not have records of all veterans. 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.8 The
resulting data may not be comparable across jurisdictions.9 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.10 The lag between a suicide event and
identification of the decedent as a veteran may be years; this delays the availability of crucial
information. Timely reporting of death certificates was identified as a core issue in a 2010
progress report on the National Strategy for Suicide Prevention.11
VHA Research into Risk and Protective Factors
The VHA conducts veteran-specific research that builds on research among the general
population to identify characteristics associated with higher rates of suicide (i.e., risk factors) and
lower rates of suicide (i.e., protective factors).12 Identifying risk and protective factors is essential
6 In addition to the BHAP, VA Medical Centers report data on known attempted and completed suicides (among other
things) to the VA Central Office through the Suicide Prevention Application Network (SPAN). U.S. Government
Accountability Office, VA Health Care: Improvements Needed in Monitoring Antidepressant Use for Major Depressive
Disorder and in Increasing Accuracy of Suicide Data, GAO-15-55, December 12, 2014.
7 The estimated number of veterans living in the United States is from VetPop2011, at http://www.va.gov/vetdata/
Veteran_Population.asp. The estimated number of veterans enrolled in VHA health care is from the VA budget
submission for FY2015, available at http://www.va.gov/budget/products.asp.
8 Both the legal authority for maintaining registries of deaths and the responsibility for issuing death certificates reside
with individual states, territories, and two cities (Washington, DC, and New York, NY).
9 Researchers at the RAND Corporation summarized variation in suicide statistics across jurisdictions in four domains:
(1) how suicides are defined or how ambiguous deaths are classified, (2) qualifications of professionals certifying a
death as a suicide, (3) the extent to which possible suicide deaths are investigated, and (4) the quality of data
management. Rajeev Ramchand et al., The War Within: Preventing Suicide in the U.S. Military, The RAND
Corporation, 2011, p. 13, http://www.rand.org; hereinafter referred to as The War Within.
10 CDC’s National Center for Health Statistics (NCHS) works cooperatively with state, territorial, and local
jurisdictions to collect information from death certificates in the National Vital Statistics System (NVSS). NCHS
extracts information from NVSS to create the National Death Index (NDI), a data set that can be combined with other
data sets for research purposes. For more information, see CDC, National Center for Health Statistics, National Death
Index, http://www.cdc.gov/nchs/ndi.htm.
11 Suicide Prevention Resource Center and Suicide Prevention Action Network (SPAN), Charting the Future of Suicide
Prevention: A 2010 Progress Review of the National Strategy and Recommendations for the Decade Ahead, 2010, p.
30; hereinafter referred to as Charting the Future.
12 National Action Alliance for Suicide Prevention, Research Prioritization Task Force, A Prioritized Research Agenda
for Suicide Prevention: An Action Plan to Save Lives, Rockville, MD, 2014.
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in order to design effective interventions aimed at lowering overall risk of suicide by reducing
risk factors and/or increase 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. Table 1 provides examples of risk and protective factors among the general
population.
Table 1. Selected Risk and Protective Factors in the General Population
Risk Factors
Protective Factors
Some major physical illnesses, mental disorders, and
Effective clinical care for physical illnesses, mental disorders,
substance use disorders
and substance use disorders
Barriers to accessing health care
Easy access to a variety of clinical interventions
Stigma associated with help-seeking behavior
Support for help-seeking behavior
Easy access to lethal means (e.g., firearms or poison)
Restricted access to lethal means (e.g., firearms or poison)
Lack of social support and sense of isolation
Strong connections to family and community support
Cultural/religious beliefs that accept suicide
Cultural/religious beliefs that discourage suicide
Source: Examples of risk and protective factors selected from U.S. Department of Health and Human Services
(HHS), Centers for Disease Control and Prevention (CDC), Injury Center: Violence Prevention, Suicide: Risk
and Protective Factors, http://www.cdc.gov/violenceprevention/suicide/riskprotectivefactors.html.
Within HHS, both the CDC13 and the National Institute of Mental Health (NIMH)14 disseminate
research on suicide risk and protective factors within the general population. Also, the Substance
Abuse and Mental Health Services Administration (SAMHSA) collects data on suicide attempts
and related behavior.15 It should be noted that risk factors for attempted suicide may differ from
risk factors for completed suicide; for example, women have a higher rate of attempted suicide,
but men have a higher rate of completed suicide.16 Despite a large number of risk and protective
factors identified by researchers, it is not yet possible to predict who will attempt or complete
suicide.17 The inability to identify individuals most in need of interventions is one of the reasons a
public health approach—with a focus on population-level interventions—is necessary for
effective suicide prevention.
Veteran-specific research on suicide risk and protective factors is necessary because the veteran
population differs from the non-veteran population on a variety of characteristics (e.g., gender
distribution), some of which may also be associated with suicide risk. Research has explored
13 Centers for Disease Control and Prevention, Suicide: Risk and Protective Factors, Atlanta, GA, http://www.cdc.gov/
ViolencePrevention/suicide/riskprotectivefactors.html.
14 HHS, National Institutes of Health (NIH), National Institute of Mental Health, Publications about Suicide
Prevention, http://www.nimh.nih.gov/health/publications/suicide-prevention-listing.shtml; and National Institute of
Mental Health, Science News about Suicide Prevention, http://www.nimh.nih.gov/science-news/science-news-about-
suicide-prevention.shtml.
15 SAMHSA asks about these topics in the National Survey on Drug Use and Health (NSDUH). See HHS, CDC,
Morbidity and Mortality Weekly Report: Suicidal Thoughts and Behaviors Among Adults ≥ 18 Years—United States,
2008 – 2009, October 21, 2011, http://www.cdc.gov/mmwr/pdf/ss/ss6013.pdf.
16 National Strategy for Suicide Prevention, p. 18.
17 For example, although the single strongest predictor of a completed suicide is a prior suicide attempt, most people
who attempt suicide do not subsequently complete suicide, and most people who complete suicides have no history of
prior attempts. See The War Within, p. 29; and Joel Paris, “Predicting and Preventing Suicide: Do We Know Enough to
Do Either?” Harvard Review of Psychiatry, vol. 14, no. 5 (2006), pp. 233-240.
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whether combat exposure is associated with risk of suicide (with mixed results).18 Veterans who
are enrolled with the VHA may differ from non-enrolled veterans, as well.
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. Administratively, both the COE and the MIRECC (as well as other centers)
fall under the Mental Health Strategic Healthcare Group, which is separate from ORD.
VHA Office of Research and Development (ORD)
In general, the ORD funds intramural research (including mental health research) by individual
VHA investigators.19 The ORD’s Health Services Research and Development Service supports
research into suicide risk factors and protective factors.20 For example, the VHA conducted a
study of suicide risk among veterans with depression (a known risk factor in the general
population, as well as among veterans).21 Another study examined characteristics associated with
suicide risk among patients seen in VHA primary care, to help identify factors that primary care
providers may be able to use to detect suicide risk.22 These studies, and others like them, can help
the VHA identify veterans at high risk of suicide, so that interventions can be targeted to them.
Center of Excellence (COE)
The COE at Canandaigua, NY, conducts research on risk and protective factors, in addition to
other suicide prevention activities. Established in August 2007 at the direction of Congress,23 the
COE has the mission of developing and studying evidence-based public health approaches to
prevention of veteran suicide, with the goal of reducing morbidity and mortality associated with
suicide in the veteran population. In pursuit of its mission, the Epidemiology and Interventions
18 VA, VHA, National Center for PTSD, The Relationship Between PTSD and Suicide, last updated January 3, 2014,
http://www.ptsd.va.gov/professional/co-occurring/ptsd-suicide.asp.
19 The ORD supports research through four research divisions: Biomedical Laboratory Research and Development
(BLR&D), Clinical Science Research and Development (CSR&D), Rehabilitation Research and Development
(RR&D), and Health Services Research and Development (HSR&D).
20 A search for “suicide” at http://www.hsrd.research.va.gov/research/ yields dozens of suicide-related studies
conducted within ORD’s Health Services Research and Development (HSR&D) Service; some of the resulting studies
investigate risk factors and/or protective factors.
21 VA, VHA, Health Services Research and Development, Risk of Death Among Veterans with Depression, Study IIR
10-176, http://www.hsrd.research.va.gov/research/abstracts.cfm?Project_ID=2141701218.
22 VA, VHA, Health Services Research and Development, Veteran Interactions with VA Primary Care Prior to Suicide,
Study IIR 10-331, http://www.hsrd.research.va.gov/research/abstracts.cfm?Project_ID=2141701170.
23 U.S. Congress, Committee of Conference, Making Appropriations for Military Quality of Life Functions of the
Department of Defense, Military Construction, the Department of Veterans Affairs, and Related Agencies for the Fiscal
Year Ending September 30, 2006, and for Other Purposes, report to accompany H.R. 2528, 109th Cong., 1st sess.,
November 18, 2005, H.Rept. 109-305 (Washington: GPO, 2006), p. 39. The committee report directed the VHA “to
place more emphasis on psychiatric care of our veterans by designating three centers of excellence to focus on mental
health/PTSD needs. These three centers will be established at Waco Medical Center, Texas; San Diego Medical Center,
California; and the Canandaigua Medical Center, New York.”
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Research Core within the COE collects and analyzes data on suicide risk and protective factors
(as well as other topics) among both veterans who use VHA services and those who do not.24
Mental Illness Research, Education, and Clinical Center (MIRECC)
The MIRECCs, also established at the direction of Congress,25 conduct research on a range of
mental health-related topics, including suicide risk factors and protective factors. Specifically, the
MIRECC of the VA Rocky Mountain Network pursues the goal of reducing suicidality in the
veteran population, by conducting research on potential contributions of cognitive and
neurobiological factors, among other activities.26 For example, one study assesses the relationship
(if any) between suicidal ideation and thinking under stress.27 Another study investigates
cognitive functioning, distress, and suicide risk in Veterans with HIV/AIDS.28 Other MIRECCs
may also conduct research related to suicide, in the course of pursuing their other goals.
Selected VHA Suicide Prevention Interventions
Suicide prevention interventions aim to reduce risk factors and/or enhance protective factors,
thereby lowering the risk of suicide. They may address entire populations (e.g., all veterans), at-
risk subgroups (e.g., veterans diagnosed with a mental disorder), or high-risk individuals (e.g.,
veterans with recent suicide attempts).
Interventions are refined in a three-stage cycle. The first stage is to develop and pilot test
interventions on a small scale to ensure that they are safe, ethical, feasible, efficacious (i.e., they
work under ideal conditions), and effective (i.e., they work under real-world conditions). If
interventions are successful in the first stage, the second stage is to implement them on a larger
scale. The third stage is to evaluate interventions that have been implemented on a larger scale, to
verify their effectiveness and determine for whom they are most effective. The three stages can
then be repeated to refine interventions, either to improve their effectiveness or to adjust them for
use with a different population (e.g., applying an intervention developed for male veterans to a
population of female veterans).
Within the VHA, the same research components that study risk and protective factors research
evaluate interventions: ORD,29 COE,30 and MIRECC.31 Both small-scale testing and large-scale
24 VA, VHA, VISN 2 Center of Excellence at Canandaigua, http://www.mirecc.va.gov/docs/2010InfoSheets/
VISN_2_CoE_Canandaigua_Info_Sheet_2010.pdf.
25 P.L. 104-262, Veterans’ Health Care Eligibility Reform Act of 1996, enacted 10/09/1996 (38 U.S.C. §7320).
26 VA, VHA, MIRECC of the VA Rocky Mountain Network (VISN 19 MIRECC), http://www.mirecc.va.gov/visn19/
index.asp.
27 VA, VHA, VISN 19 MIRECC, The Relationship Between Suicidal Ideation and Thinking Under Stress,
http://www.mirecc.va.gov/visn19/research/projects.asp.
28 VA, VHA, VISN 19 MIRECC, Assessment of Cognitive Functioning as it Relates to Suicide Risk in Veterans with
HIV/AIDS, http://www.mirecc.va.gov/visn19/research/projects.asp.
29 Suicide prevention is a goal of the Mental Health Quality Enhancement Research Initiative (QUERI) within ORD.
See VA Mental Health QUERI Center, Strategic Plan, December 2011, http://www.queri.research.va.gov/about/
strategic_plans/mh.pdf; and VA Mental Health QUERI Center, Fact Sheet: Mental Health, July 2014,
http://www.queri.research.va.gov/about/factsheets/mh_factsheet.pdf.
30 The COE at Canandaigua evaluates implementation of suicide prevention initiatives.
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evaluation are integral to suicide prevention interventions; however, rigorous research on
effectiveness is difficult and lacking for most interventions, both within and outside the VHA.32
Easy Access to Care
Easy access to care is a protective factor against suicide, and recent laws have included provisions
aimed at increasing veterans’ access to VHA-provided or VHA-funded care (not limited to mental
health care). The Veterans Access, Choice, and Accountability Act of 2014 (P.L. 113-146, as
amended) aims to increase access to care by requiring the VHA to authorize reimbursement for
non-VHA care under certain circumstances.33 More recently, the Clay Hunt Suicide Prevention
for American Veterans Act (P.L. 114-2) included a one-year extension of the existing five-year
post-discharge period of enhanced enrollment in VHA health care for certain veterans.34 The
Congressional Budget Office (CBO) estimates that this provision will result in the enrollment of
about 4,600 veterans, including 1,400 who would not otherwise be able to enroll.
VHA policy requires that emergency mental health care be available 24 hours per day through
emergency rooms at VA facilities or local, non-VA hospitals;35 that new patients referred for
mental health services receive an initial assessment within 24 hours and a full evaluation
appointment within 14 days; and that follow-up appointments for established patients be
scheduled within 30 days.36 The extent to which these policies are implemented in practice has
been questioned in congressional testimony,37 news media,38 and survey responses from both
providers and patients.39
(...continued)
31 For example, the MIRECC of the VA Rocky Mountain Network is conducting a study to determine whether
providing prescription medication in blister packages (rather than bottles) is associated with greater treatment
adherence and fewer suicide-related overdoses among those at high risk of suicide. VA, VHA, Blister Packaging
Medications, http://www.mirecc.va.gov/visn19/research/projects.asp.
32 The War Within, p. 13.
33 See CRS Report R43704, Veterans Access, Choice, and Accountability Act of 2014 (H.R. 3230; P.L. 113-146).
34 See CRS Report R43547, Veterans’ Medical Care: FY2015 Appropriations; Appendix A describes the eight Priority
Groups for VA enrollment and the eligibility criteria for each.
35 VA, VHA, Uniform Mental Health Services in VA Medical Centers and Clinics, VHA Handbook 1160.01,
September 11, 2008; and VA, VHA, About VA Mental Health, http://www.mentalhealth.va.gov/
vamentalhealthgroup.asp.
36 VA, VHA, Uniform Mental Health Services in VA Medical Centers and Clinics, VHA Handbook 1160.01,
September 11, 2008. In accordance with the Veterans Access, Choice, and Accountability Act of 2014 (P.L. 113-146),
the VHA has established a wait-time goal (not specific to mental health) “to furnish care within 30 days of either the
date that an appointment is deemed clinically appropriate by a VA health care provider, or if no such clinical
determination has been made, the date a veteran prefers to be seen.” Department of Veterans Affairs, “Expanded
Access to Non-VA Care Through the Veterans Choice Program,” 79 Federal Register 65571, November 5, 2014.
37 See, for example, U.S. Congress, Senate Committee on Veterans’ Affairs, VA Mental Health Care: Ensuring Timely
Access to High-Quality Care, 113th Cong., 1st sess., March 20, 2013; U.S. Congress, House Committee on Veterans’
Affairs, Subcommittee on Health, Service Should Not Lead to Suicide: Access to VA’s Mental Health Care, 113th
Cong., 2nd sess., July 10, 2014; and U.S. Congress, Senate Committee on Veterans’ Affairs, Mental Health and Suicide
Among Veterans, 113th Cong., 2nd sess., November 19, 2014.
38 Meghan Hoyer and Tom Vanden Brook, “New data show long wait times remain at many VA hospitals,” USA
Today, November 16, 2014.
39 VHA, 2013 U.S. Department of Veterans Affairs National Mental Health Provider Survey,
http://www.hospitalcompare.va.gov/.
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Other efforts to increase access to mental health care focus on known barriers such as lack of
understanding or awareness of mental health care, stigma associated with mental illness, concerns
about VHA care, and challenges in scheduling appointments.40 The VHA provides information to
help increase awareness of mental health care services, reduce the stigma associated with seeking
care, and correct misconceptions about VHA care.41 Some mental health and substance use
evaluation and treatment services have been integrated into other treatment settings, which both
increases the convenience and reduces the stigma associated with seeking care.42 The VHA is
required to conduct a three-year pilot program using outreach programs and peer support
networks to assist recently discharged veterans in accessing VHA mental health services.43
Screening, Assessment, and Follow-Up
Some types of screening are supported by evidence that they reduce the likelihood of suicide.44
The U.S. Preventive Services Task Force (USPSTF), which makes evidence-based
recommendations about screenings and other clinical preventive services, recommends
depression screening in primary care settings “when appropriate systems are in place to ensure
adequate diagnosis, treatment, and follow-up.”45 That is, the recommendation to use screenings is
contingent upon the availability of further evaluation, treatment, and follow-up care. Without
such systems in place, screening would serve little purpose.
VHA policy requires screening for a variety of risk factors, including but not limited to
depression, posttraumatic stress disorder (PTSD), and alcohol abuse. Those who screen positive
are evaluated further and offered treatment if found to have a mental health problem. Positive
screens for PTSD or depression, in particular, are followed by a suicide risk assessment.46
Treatment of Mental Illness
For individuals identified as having mental illness, clinical interventions may be indicated
regardless of specific risk of suicide. Clinical interventions may include pharmacotherapy,
psychotherapy, or both.47 The VA and the DOD have jointly developed clinical practice guidelines
40 U.S. Government Accountability Office, VA Mental Health: Number of Veterans Receiving Care, Barriers Faced,
and Efforts to Increase Access, GAO-12-12, October 14, 2011, pp. 15-17, http://www.gao.gov/products/GAO-12-12.
41 See for example VA, VHA, Guide to VA Mental Health Services for Veterans & Families, July 2012,
http://www.mentalhealth.va.gov/docs/MHG_English.pdf; and VA, VHA, Office of Rural Health, Mental Health
Stigma: 10 Things You Should Know About, http://www.ruralhealth.va.gov/ruralclergytraining/10things/stigma.asp.
42 Evelyn Chang and Alissa Simon, Report on Integrating Mental Health Into PACT (IMHIP) in the VA, VA Office of
Patient Care Services, September 2013, http://www.hsrd.research.va.gov/publications/internal/IMHIP-Report.pdf.
43 See Section 5 of the Clay Hunt Suicide Prevention for American Veterans Act (P.L. 114-2).
44 The War Within, p. 119.
45 An update to this recommendation is in progress. USPSTF, Final Recommendation Statement: Suicide Risk in
Adolescents, Adults, and Older Adults: Screening, http://www.uspreventiveservicestaskforce.org/Page/Document/
RecommendationStatementFinal/suicide-risk-in-adolescents-adults-and-older-adults-screening#Pod5.
46 VA, VHA, Programs for Veterans with Post-Traumatic Stress Disorder (PTSD), VHA Handbook 1160.03, March
12, 2010, p. 5, http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2174.
47 Morton M. Silverman et al., “Reflections on Expert Recommendations for U.S. Research Priorities in Suicide
Prevention,” American Journal of Preventive Medicine, vol. 47, no. 3S2 (2014), pp. S97-S101.
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for treatment of some conditions, to help clinicians select treatments that research has shown to
be effective (i.e., evidence-based treatments).48
A 2011 evaluation of VHA mental health care finds that treatment in the VHA is generally better
than in other systems on a variety of measures, but still has room for improvement. 49 In
particular, the evaluation finds that evidence-based treatments, while widely available, are not
usually provided.50 Researchers based this finding on a review of medical records, which showed
that prescriptions for medication were often not filled for as long as recommended and that
psychotherapy, as documented, was often not delivered according to evidence-based guidelines.
Additionally, the evaluation found that assessment of veterans’ symptoms is lacking, both at the
beginning of treatment and during treatment (to track progress).51 Another third-party evaluation
of the VHA’s mental health care system is underway, to be completed by the end of FY2017.52
Third-party evaluations of VHA mental health care and suicide prevention programs are now
required annually, with the first to be completed by the end of FY2018.53
Suicide Prevention Coordinators
Per department policy, every VA Medical Center has at least one suicide prevention coordinator,
whose responsibilities include (among other things) tracking patients who have been identified as
at high risk for suicide. The VHA’s computerized patient record system enables clinicians to flag
high-risk patients, and policy requires that safety plans be developed for them.54 A safety plan is a
written document developed jointly by a patient and a clinician that identifies strategies for
coping in a crisis (e.g., recognizing warning signs and contacting family members, friends, or
mental health providers). Outside the VHA, the use of suicide prevention coordinators has not
been widely adopted, although some components of the program (e.g., safety plans) are widely
used. The suicide prevention coordinator program has been identified as a practice worth
emulating by a DOD task force on suicide prevention.55
48 VA and DOD, VA/DOD Clinical Practice Guidelines, http://www.healthquality.va.gov/.
49 Katherine E. Watkins and Harold Alan Pincus, Veterans Health Administration Mental Health Program Evaluation:
Capstone Report, Altarum Institute and RAND Health, 2011, p. 153; hereinafter referred to as VHA Mental Health
Program Evaluation.
50 VHA Mental Health Program Evaluation. For example, among veterans for whom maintenance medication is
recommended, less than one-third received the recommended continuous treatment (p. 160). Similarly, among veterans
receiving psychotherapy, “most did not include elements of an evidence-based modality” (p. 154).
51 VHA Mental Health Program Evaluation. Less than two-thirds of veterans in a new treatment episode “have a
documented assessment of their housing and employment needs” (p. 161). Among veterans with major depressive
disorder who were receiving psychotherapy, less than a quarter (23%) “had documentation of an assessment of
response to psychotherapy” (p. 155).
52 U.S. Congressional Budget Office, Cost Estimate for H.R. 203 Clay Hunt Suicide Prevention for American Veterans
Act, January 28, 2015, pp. 2-3.
53 See Section 2 of the Clay Hunt Suicide Prevention for American Veterans Act (P.L. 114-2).
54 VA, Office of Inspector General, Healthcare Inspection: Evaluation of Suicide Prevention Program Implementation
in VHA Facilities, January–June 2009, Report No. 09-00326-223, Washington, DC, September 22, 2009; and VA,
Office of Inspector General, Combined Assessment Program Summary Report: Re-Evaluation of Suicide Safety Plan
Practices in Veterans Health Administration Facilities, Report No. 11-01380-128, Washington, DC, March 22, 2011.
55 Department of Defense Task Force on the Prevention of Suicide by Members of the Armed Forces, The Challenge
and the Promise: Strengthening the Force, Preventing Suicide, and Saving Lives, August 2010, pp. 55, 89,
http://www.sprc.org/library_resources/items/challenge-and-promise-strengthening-force-preventing-suicide-and-
saving-live; hereinafter referred to as The Challenge and the Promise.
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Suicide Hotline
Suicide hotlines are telephone numbers individuals can call for help in crisis situations (e.g., at
the moment they are considering suicide). Hotlines are generally toll-free and available around
the clock. The Veterans Crisis Line is a joint effort of the VHA and SAMHSA.56 The main line (1-
800-273-8255) is the National Suicide Prevention Lifeline, operated by SAMHSA.57 Veterans (or
others calling with concerns about veterans) may select option 1 to be directed to the VHA’s
Veterans Crisis Line, answered by staff at the COE in Canandaigua, NY. Callers may remain
anonymous or disclose their identities in order to allow the COE staff to access their VA medical
records during the call. The Veterans Crisis Line is supplemented by an online chat service
(http://www.VeteransCrisisLine.net/chat) and support via text messaging (text 838255). The
Veterans Crisis Line has answered more than 1.25 million calls since it began in 2007, has
engaged in more than 175,000 chats since it added the chat service in 2009, and has responded to
more than 24,000 texts since it added the text-messaging service in 2011.58
The evidence base for suicide hotlines is not sufficient to determine their effectiveness in
reducing suicide rates, due to the difficulties inherent in conducting such evaluations.59 The
confidentiality of suicide hotlines renders follow-up with each individual caller impossible
(except in cases when a caller voluntarily discloses his or her identity). Moreover, national
hotlines, such as those operated by SAMHSA and the VHA, serve a large geographic area. A
range of other interventions may be in place in localities within the hotline’s reach, such that any
change in the suicide rate may not be attributable to the hotline.
Education and Awareness
The VHA offers suicide prevention education and outreach to staff, patients, and surrounding
communities. All VHA health care providers are required to complete web-based training on
suicide risk and intervention and to pass a post-test.60 VHA Suicide Prevention Coordinators are
required to conduct outreach activities in their local communities.61 The VHA has co-sponsored
(with the Department of Defense) conferences on suicide prevention to educate clinicians and has
sponsored Suicide Prevention Days to raise awareness.
56 VA, VHA and Department of Health and Human Services (HHS), Substance Abuse and Mental Health Services
Administration (SAMHSA), Veterans Crisis Line, http://www.veteranscrisisline.net/.
57 HHS, SAMHSA, National Suicide Prevention Lifeline, http://www.suicidepreventionlifeline.org/.
58 VA, VHA and HHS, SAMHSA, About the Veterans Crisis Line, http://www.veteranscrisisline.net/About/
AboutVeteransCrisisLine.aspx.
59 J. John Mann et al., “Suicide Prevention Strategies: A Systematic Review,” Journal of the American Medical
Association, vol. 294, no. 16 (October 26, 2005), pp. 2064-2074.
60 VA, VHA, Mandatory Suicide Risk and Intervention Training for VHA Health Care Providers, VHA Directive 1071,
June 27, 2014, http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3011.
61 VA, VHA, Office of Patient Care Services, Office of Mental Health Services, Fact Sheet: VA Suicide Prevention
Program, March 2012, http://www.visn20.med.va.gov/VISN20/docs/SuicidePreventionFactSheet32312.pdf.
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Limited Access to Lethal Means
The three most common means of completing suicide among the general population are firearms
(50%), suffocation (24%), and poisoning (18%).62 Evidence supports restricting access to lethal
means (e.g., firearms, gas, drugs) as a way to reduce suicide rates.63 In some cases, means
restriction may delay a suicide attempt long enough that the impulse passes, which may require
only several minutes.64 In other cases, an individual may attempt suicide using a different method
that is less lethal (e.g., drugs rather than firearms). The VHA has a gun safety program (as both a
child safety initiative and a suicide prevention initiative), which includes distribution of free gun
locks and dissemination of gun safety information.65 The VHA also conducts research on blister
packaging medications as a potential way to reduce the incidence of medication overdoses.66
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.”67 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.68 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.”69
62 Mechanism of injury for suicides among the general U.S. population in CY2007 identified from Centers for Disease
Control and Prevention, National Center for Health Statistics. Compressed Mortality File 1999-2007. CDC WONDER
On-line Database, compiled from Compressed Mortality File 1999-2007 Series 20 No. 2M, 2010,
http://wonder.cdc.gov/cmf-icd10.html.
63 Marco Sarchiapone et al., “Controlling Access to Suicide Means,” International Journal of Environmental Research
and Public Health, vol. 8, no. 12 (2011), pp. 4550-4562; and Paul S.F. Yip et al., “Suicide 3: Means Restriction for
Suicide Prevention,” The Lancet, vol. 379, no. 9834 (2012), pp. 2393-2399.
64 Catherine W. Barber and Matthew J. Miller, “Reducing a Suicidal Person’s Access to Lethal Means of Suicide: A
Research Agenda,” American Journal of Preventive Medicine, vol. 47, no. 3S2 (2014), pp. S264-S272.
65 VA, VHA, Health Awareness Campaigns: Gun Safety, http://www.womenshealth.va.gov/WOMENSHEALTH/
outreachmaterials/safety/gunsafety.asp; and Caitlin Thompson, Gun safety: An important conversation during Suicide
Prevention Month, VA, VHA, September 30, 2014, http://www.blogs.va.gov/VAntage/15434/gun-safety-an-important-
conversation-during-suicide-prevention-month/.
66 For example, the MIRECC of the VA Rocky Mountain Network is conducting a study to determine whether
providing prescription medication in blister packages (rather than bottles) is associated with greater treatment
adherence and fewer suicide-related overdoses among those at high risk of suicide. VA, VHA, Blister Packaging
Medications, http://www.mirecc.va.gov/visn19/research/projects.asp.
67 Charting the Future, p. 11.
68 See, for example, U.S. Congress, House Committee on Veterans’ Affairs, Subcommittee on Health, Service Should
Not Lead to Suicide: Access to VA’s Mental Health Care, 113th Cong., 2nd sess., July 10, 2014; and U.S. Congress,
Senate Committee on Veterans’ Affairs, Ensuring Veterans Receive the Care They Deserve—Addressing VA Mental
Health Program Management, 113th Cong., 2nd sess., November 19, 2014.
69 VHA Mental Health Program Evaluation, p. 153.
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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.
Improving the Timeliness and Accuracy of Surveillance Data
Challenges in suicide surveillance include timeliness of data, consistent classification of deaths as
suicides, and accuracy of information. Addressing these challenges requires the involvement of
entities other than VHA.
Recommendations related to the timeliness of suicide surveillance data include ensuring that the
CDC’s ability to compile national death data expeditiously is not limited by a lack of resources;
coordinating the annual analysis of veteran suicide data among VA, DOD, and HHS; and
establishing “reasonable time requirements for states to provide death data to the CDC.”70 It
should be noted that states, territories, and cities voluntarily share vital statistics with the CDC, so
offering incentives for timely data might be more feasible than imposing requirements.
It is widely believed that inconsistent reporting of suicides across jurisdictions, as well as
underreporting of suicides in general, limits the effectiveness of surveillance efforts.71
Classification of a death as a suicide requires a determination that the death is both self-inflicted
and intentional. Determining the decedent’s intent is difficult, and coroners or medical examiners
may feel pressure not to classify a death as suicide, due to the stigma associated with suicide.
Suicides may be underreported when the manner of death is misclassified as “undetermined” or
“accidental” (e.g., poisonings or single-vehicle crashes). Additionally, each jurisdiction (state,
territory, or city) has its own requirements for investigating deaths, leading to variability across
jurisdictions.
The GAO recommends that the VA implement processes to improve the completeness, accuracy,
and consistency of data reported through the VHA’s Behavioral Health Autopsy Program (BHAP)
system.72 Beyond that, the VA must rely on outside data sources (e.g., the DOD) to identify
decedents as veterans if they are not enrolled with the agency.73
70 Margaret Harrell and Nancy Berglass, Losing the Battle: The Challenge of Military Suicide, Center for a New
American Security (CNAS), Washington, DC, October 2011, p. 9; hereinafter referred to as Losing the Battle. CNAS is
a 501(c)3 tax-exempt nonprofit organization that describes itself as independent and non-partisan. See
http://www.cnas.org/about.
71 See for example Stefan Timmermans, “Suicide determination and the professional authority of medical examiners.,”
American Sociological Review, vol. 70, no. 2 (2005), pp. 311-333; Hugh P. Whitt, “Where did the bodies go? The
social construction of suicide data, New York City, 1976-1992,” Sociological Inquiry, vol. 76, no. 2 (2006), pp. 166-
187; M.J. Breiding and B. Wiersema, “Variability of undetermined manner of death classification in the U.S.,” Injury
Prevention, vol. 12(Suppl II) (2006), pp. ii49-ii54.
72 U.S. Government Accountability Office, VA Health Care: Improvements Needed in Monitoring Antidepressant Use
for Major Depressive Disorder and in Increasing Accuracy of Suicide Data, GAO-15-55, December 12, 2014,
http://www.gao.gov/products/GAO-15-55.
73 The enrollment file includes veterans receiving benefits from the Veterans Benefits Administration, even if the
veterans are not receiving care from VHA. VA researchers conducting a one-time study (not ongoing surveillance)
combined information from the National Death Index with information from the DOD’s Defense Manpower Data
Center (DMDC) to identify suicides among veterans regardless of VA enrollment. The study was limited to veterans
who served in Operations Enduring Freedom and/or Iraqi Freedom and who were separated alive from active duty
between October 2001 and December 2005. See Han K. Kang and Tim A. Bullman, “Letter: Risk of Suicide Among
US Veterans After Returning From the Iraq or Afghanistan War Zones,” Journal of the American Medical Association,
(continued...)
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Building the Evidence Base
Developing an adequate evidence base is necessary both to identify risk and protective factors
and to develop and disseminate effective interventions. Recommendations include increased
information sharing, collaboration, and dialogue across areas of public health, among government
agencies, and between congressional committees.
Suicide prevention tends to operate in its own silo, even though suicide has some of the same risk
and protective factors as other public health problems. Increased collaboration and dialogue
between suicide prevention and other areas of public health “will help prevent the field from
endlessly recreating wheels and spreading the limited funds too broadly to make a sustainable
difference.”74
If agencies (federal, state, or local) engage in ongoing collaboration and dialogue, sharing
evaluations of existing interventions and research into new interventions, they may prevent
unnecessary duplication of effort and help build the evidence base more quickly.75 (Note that
replication of studies is an integral part of the research process, so a distinction may be made
between appropriate and unnecessary duplication of effort.) Specific recommendations include
sharing research findings between the VA, DOD, and HHS76 and fast-tracking all phases of the
intervention cycle (designing and pilot testing interventions, implementing interventions, and
evaluating interventions), as well as the dissemination of the knowledge gained in each phase.77
Some have also recommended that the House and Senate Committees on Veterans’ Affairs initiate
discussions with the House and Senate Armed Services Committees to develop provisions
addressing veteran suicide in the National Defense Authorization Act.78
Increasing Access to High-Quality Mental Health Care
Providing timely access to high-quality mental health care has been a challenge for the VHA. The
Veterans Access, Choice, and Accountability Act of 2014 (P.L. 113-146, as amended) aims to
increase access for veterans seeking VHA care (not limited to mental health care).79 Among other
things, the act establishes the Veterans Choice Program, which requires the VHA to authorize
reimbursement for non-VHA care under specified conditions. One such condition occurs when a
qualified veteran is unable to schedule an appointment within the VHA’s wait-time goals. In
accordance with the act, the VHA has established a wait-time goal “to furnish care within 30 days
of either the date that an appointment is deemed clinically appropriate by a VA health care
(...continued)
vol. 300, no. 6 (2008), pp. 652-653.
74 Charting the Future, p. 40.
75 Losing the Battle, p. 9; and Charting the Future, p. 40.
76 Losing the Battle, p. 9.
77 Charting the Future, p. 40.
78 Losing the Battle, p. 9.
79 See CRS Report R43704, Veterans Access, Choice, and Accountability Act of 2014 (H.R. 3230; P.L. 113-146).
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provider, or if no such clinical determination has been made, the date a veteran prefers to be
seen.”80
Access to VHA mental health care is determined in part by the availability of providers. Pursuant
to P.L. 113-146, the VA Office of Inspector General (OIG) identified five occupations with the
largest shortages: medical officer (i.e., physician), nurse, physician assistant, physical therapist,
and psychologist.81 The OIG report does not specify physician specialties (e.g., psychiatrists). A
shortage of psychologists might be mitigated by hiring other providers with similar scopes of
practice (i.e., social workers, mental health counselors, and marriage and family therapists);82
however, the VHA may also have shortages among those occupations as the OIG report lists only
the top five.83 The VHA has both long-standing and recently established mechanisms available to
improve recruitment and retention of providers (e.g., educational debt repayment programs).
The Clay Hunt Suicide Prevention for American Veterans Act (P.L. 114-2) aims to expand access
to care by extending the existing period of enhanced enrollment, requiring a pilot program to
conduct community outreach, requiring a pilot program to repay the education loans of qualified
psychiatrists, and authorizing collaboration with nonprofit mental health organizations.
When veterans gain access to care—within or outside the VHA—they may not always receive
high-quality care.84 While the VHA has made progress in disseminating knowledge about
evidence-based treatment (e.g., through clinical practice guidelines developed jointly with DOD),
that does not guarantee implementation of such treatments.85 A 2011 evaluation of VHA mental
health care finds room for improvement in the use of evidence-based treatments.86 Another third-
party evaluation of the VHA’s mental health care system is underway (to be completed by the end
of FY2017),87 and independent evaluations of VHA mental health care and suicide prevention
programs are required annually (with the first to be completed by the end of FY2018).88
A 2014 report by the RAND Corporation indicates that only 13% of evaluated mental health
providers (not limited to VHA providers) met study criteria for readiness to provide veteran-
friendly, high-quality care.89 Providers working within the VHA or a military setting were more
80 Department of Veterans Affairs, “Expanded Access to Non-VA Care Through the Veterans Choice Program,” 79
Federal Register 65571, November 5, 2014.
81 VA, Office of Inspector General, OIG Determination of Veterans Health Administration’s Occupational Staffing
Shortages, Report No. 15-00430-103, January 30, 2015.
82 For more about scopes of practice, see CRS Report R43255, The Mental Health Workforce: A Primer.
83 Section 301 of P.L. 113-146 also requires the VA to submit more detailed staffing reports to the Committees on
Veterans’ Affairs in the House and Senate.
84 VHA Mental Health Program Evaluation. For example, among veterans for whom maintenance medication is
recommended, less than one-third received the recommended continuous treatment (p. 160). Similarly, among veterans
receiving psychotherapy, “most did not include elements of an evidence-based modality” (p. 154).
85 VA, VHA and DOD, VA/DOD Clinical Practice Guidelines, http://www.healthquality.va.gov/.
86 VHA Mental Health Program Evaluation.
87 U.S. Congressional Budget Office, Cost Estimate for H.R. 203 Clay Hunt Suicide Prevention for American Veterans
Act, January 28, 2015, pp. 2-3.
88 P.L. 114-2 Section 2.
89 The three study criteria were as follows: (1) providers reported having been trained in an evidenced-based therapy for
posttraumatic stress disorder and major depressive disorder, (2) providers reported using evidence-based treatments for
patients with those conditions, and (3) providers scored at least 15 on a 22-point scale of cultural competency with a
military or veteran population. Terri Tanielian et al., Ready to Serve: Community-Based Provider Capacity to Delivery
Culturally Competent, Quality Mental Health Care to Veterans and Their Families, The RAND Corporation, Santa
(continued...)
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likely than others to meet the criteria, which may raise questions for some about increasing the
use of non-VHA care. The report recommends conducting better assessments of civilian provider
capacity, assessing the impact of trainings in cultural competency on provider capacity, expanding
access to effective trainings in selected evidence-based approaches, and facilitating providers’ use
of evidence-based approaches.
(...continued)
Monica, CA, 2014.
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Appendix. Public Laws Addressing VHA Suicide
Prevention Efforts
Since Operations Enduring Freedom and Iraqi Freedom began, five public laws have addressed
VHA suicide prevention efforts. Relevant provisions of each are summarized below.
Joshua Omvig Veterans Suicide Prevention Act
The Joshua Omvig Veterans Suicide Prevention Act (P.L. 110-110), enacted in 2007, required the
VA Secretary to develop and implement a comprehensive suicide prevention program, and to
report to Congress on the program. The Congressional Budget Office (CBO) estimated that
implementing the Joshua Omvig Veterans Suicide Prevention Act would have “little, if any, cost,”
because the VA already had implemented or was planning to implement each of the specific
requirements.90 The textbox below lists the required elements and additional authorized elements
of the comprehensive suicide prevention program.
Joshua Omvig Veterans Suicide Prevention Act (P.L. 110-110)
Required elements of the comprehensive suicide prevention program include the following:
•
mandatory suicide prevention training for appropriate VA staff and contractors;
•
designation of a suicide prevention counselor at each VA medical center;
•
outreach and education for veterans and their families to promote mental health;
•
mental health assessments of veterans and referrals to appropriate treatment;
•
availability of 24-hour mental health care for veterans;
•
research on best practices for suicide prevention; and
•
research on mental health among veterans with military sexual trauma.
Additional authorized (but not required) elements include the following:
•
a 24-hour tol -free hotline staffed by trained mental health personnel;
•
peer support counseling; and
•
other actions to reduce the incidence of suicide among veterans.
National Defense Authorization Act for Fiscal Year 2008
Section 1611 of the National Defense Authorization Act for Fiscal Year 2008 (P.L. 110-181)
directed the VA and DOD Secretaries to jointly develop a comprehensive care and transition
policy for servicemembers recovering from serious injuries or illnesses related to their military
service. The law specified that the policy must address (among other things) the training and
skills of health care professionals, recovery coordinators, and case managers, to ensure that they
are able to detect and report early warning signs of suicidal thoughts or behaviors, along with
90 U.S. Congressional Budget Office, Cost Estimate for H.R. 327 Joshua Omvig Veterans Suicide Prevention Act,
March 19, 2007; and U.S. Congressional Budget Office, Cost Estimate for S.4797 Joshua Omvig Veterans Suicide
Prevention Act, July 10, 2007.
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other behavioral health concerns. The law further specified that the policy must include tracking
the notifications made by recovery care coordinators, medical care case managers, and non-
medical care managers to health care professionals regarding suicidal thoughts or behaviors,
along with other behavioral health concerns. A 2009 Government Accountability Office report
indicates that DOD and VA have developed the relevant policies.91
Veterans’ Benefits Improvement Act of 2008
Section 809 of the Veterans’ Benefits Improvement Act of 2008 (P.L. 110-389) grants the VA
Secretary authority to advertise in the media for various purposes, including suicide prevention.
Since enactment the VA has promoted the Veterans Crisis Line, for example, by placing
advertisements on city buses and releasing public service announcements.92
Caregivers and Veterans Omnibus Health Services Act of 2010
Section 403 of the Caregivers and Veterans Omnibus Health Services Act of 2010 (P.L. 111-163)
requires the VA Secretary to conduct a study to determine the total number of veteran suicides
(not limited to veterans using VA services) between January 1, 1999, and May 5, 2010 (i.e., the
date of enactment). The in-progress study, dubbed the State Mortality Data Project, is described in
a VA report published in February 2013.93 At the same time, the VA released a response to the
report, which indicated (among other things) that a follow-up report was to be issued in May
2013.94 In January 2014, the VA released an update that includes some information about suicides
among veterans who do not use VA health care services in 23 states.95 A full accounting of
suicides among all veterans in all states has yet to be publicly released.
Clay Hunt Suicide Prevention for American Veterans Act
Enacted on February 12, 2015, the Clay Hunt Suicide Prevention for American Veterans Act (P.L.
114-2) has eight sections, including the short title (Section 1). Section 2 requires the VA Secretary
to have an independent entity conduct annual evaluations of VHA mental health care and suicide
prevention programs, with the first evaluation to be completed by the end of FY2018. Section 3
requires the VA Secretary to maintain a website with up-to-date information about VHA mental
health care services. Section 4 requires the VA Secretary to undertake a three-year pilot program
to repay the education loans of at least 10 eligible psychiatrists (or psychiatric residents in their
91 U.S. Government Accountability Office, Recovering Servicemembers: DOD and VA Have Jointly Developed the
Majority of Required Policies but Challenges Remain, GAO-09-728, July 2009, p. 25.
92 DOD-VA Suicide Prevention Conference, Remarks by Secretary Eric K. Shinseki, Washington, DC, January 11,
2010, http://www.va.gov/opa/speeches/2010/10_0111hold.asp; and VA, “Industry Recognizes VA Campaigns for
Raising Public Awareness for Veterans Mental Health Care,” press release, September 19, 2012, http://www.va.gov/
opa/pressrel/pressrelease.cfm?id=2384.
93 Janet Kemp and Robert Bossarte, Suicide Data Report, 2012, VA, Mental Health Services, Suicide Prevention
Program, February 1, 2013, http://www.va.gov/opa/docs/suicide-data-report-2012-final.pdf.
94 VA, 2012 Suicide Data Report: VHA Response and Executive Summary, February 1, 2013, http://www.va.gov/opa/
docs/Response-and-ExecSum-Suicide-Data-Report-2012-final.pdf.
95 VA, VHA, Suicide Rates in VHA Patients through 2011 with Comparisons with Other Americans and Other
Veterans Through 2010, January 2014, http://www.mentalhealth.va.gov/docs/
Suicide_Data_Report_Update_January_2014.pdf.
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final year of training) in exchange for two or more years of obligated service. Section 5 requires
the VA Secretary to undertake a three-year pilot program to conduct community outreach in at
least five of the VHA’s 21 Veterans Integrated Service Networks (geographic regions). Section 6
authorizes the VA Secretary to collaborate with nonprofit mental health organizations and requires
the VA Secretary to appoint a Director of Suicide Prevention Coordination to manage such
efforts. Section 7 extends by one year (beginning on the date of enactment) the existing five-year
post-discharge period of enhanced enrollment in VHA health care for certain veterans.96 Section 8
prohibits new appropriations to carry out the act. The CBO estimated that implementing the act
would cost $24 million over six years (2015–2020).97
Author Contact Information
Erin Bagalman
Analyst in Health Policy
ebagalman@crs.loc.gov, 7-5345
Acknowledgments
The author gratefully acknowledges the work of Amber Wilhelm, who created the figure in this report.
96 For more information about enrollment in VHA health care, see CRS Report R42747, Health Care for Veterans:
Answers to Frequently Asked Questions.
97 U.S. Congressional Budget Office, Cost Estimate for H.R. 203 Clay Hunt Suicide Prevention for American Veterans
Act, January 28, 2015.
Congressional Research Service
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