Healthcare Inspection: Overview of VA Suicide Prevention Efforts and Data Collection

At the request of Senator Bill Nelson, OIG conducted a healthcare review to address questions regarding VA suicide prevention efforts and suicide data collection: • How do you know if VA’s suicide prevention programs are working and what percent of veterans who die by suicide have been under the care of the Veterans Health Administration (VHA)? • Are data on suicides turned over to mental health providers in real time; what risk factors associated with higher veteran suicides are being explored in-depth, and by whom; and what ways can be identified to gather more reliable suicide data? We found that VHA tracked suicide rates of veterans and other VHA users by matching suicide deaths from the National Death Index; state-based reporting and Suicide Prevention Applications Network initiatives may not have included the full population of veteran suicides; and the VA/Department of Defense (DOD) Suicide Data Repository was developed. We found that real time data was not available to mental health providers in all states; VHA implemented a predictive analytics risk model; and non-VA researchers analyzed military service members’ social media posts for mental health status changes/suicidal ideation to determine suicide risk factors. We found that Veterans Integrated Service Network (VISN) 2 Center of Excellence and VISN 19 Mental Illness Research, Education and Clinical Center had over 20 suicide prevention research studies and projects; reliability of suicide data was contingent on usage of clear, standardized terminology; training was critical for persons responsible for completing the medical portion of the death certificate; and VHA and DOD Suicide Prevention program staff were developing a sharing agreement to establish a routine method to transfer data. This OIG review was informational and had no recommendations.