Watchdog Supports Whistleblower Allegations That VA Mistreats Suicidal Vets

Another federal agency that does more harm than good


Mark Sardella

Last month, I wrote about Brandon Coleman, a Veterans Administration whistleblower who claimed he was targeted for retaliation after voicing his concerns that the massive federal agency has been mishandling the treatment of suicidal veterans. His allegations echoed those made by Dr. Katherine Lynn Mitchell to the House Committe on Veterans Affairs last summer (she voiced her support of Coleman in an email to me). Now the U.S. Government Accountability Office seems to agree—the official watchdog just published a report charging that the VA is fumbling the recording of suicides among veterans, underestimating the prevalence of major depressive disorder among its patients, and failing to properly track the treatment of those under care.

in a report published yesterday, the GAO reviewed the Behavioral Health Autopsy Program, which is intended to "improve VA's suicide prevention efforts by identifying information that VA can use to develop policy to help prevent future suicides." What it found was incomplete or inaccurate information in over half of records. Data that was entered was inconsistent because VA medical centers interpreted their guidance differently—which matched the shoddy review of the records that were compiled.

Record-keeping is also terrible for depressed patients undergoing treatment who may be at risk of suicide. Imprecise coding by caregivers means they're not all being entered in the system the same way, so that their diagnoses and treatment can't be properly tracked.

Not that the treatment veterans receive for treatment is great shakes. The VA apparently hands many vets suffering from depression antidepressants without keeping a proper eye on the patients' conditions.

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.

This is especially concerning if you know that antidepressants can actually increase the risk of suicide in some patients. That's more of a concern among younger people, but it's still something that should be monitored.

So the VA has been targeting whistleblowers because they raised concerns about the poor treatment of suicidal veterans that have now been supported by the government itself.

Update: Rep. Seth Moulton (D-Mass.), a Marine Corps veteran, recently detailed his lousy experience with VA health care, ranging from shitty recordkeeping, to poor service, to improper medication.

NEXT: Power + Secrecy = Suspicion

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  1. Whoa – wait a minute. I understood it to be the case the The Light Worker had fixed all that was wrong with VA hospitals, like, in…..a long time ago, or something.


    1. He was mad as hell when he found out about it in the papers just like the rest of us.

      1. “What the….I CAN’T BELIEVE IT!”

    2. Surely, when Conrade Obama finds out about this…

  2. Also

    “DATA FIELDS LEFT BLANK” for the win!!

  3. This is especially concerning if you know that antidepressants can actually increase the risk of suicide in some patients. That’s more of a concern among younger people, but it’s still something that should be monitored.

    Those younger people are the vets currently at a high risk of suicide, especially soon after redeployment home. We in the ILARNG found this out in a hard and bitter way, despite our best efforts. Seems like the VA ain’t even trying.

    1. This makes me angry and sad.

      1. But certainly not angry enough to do or say something untoward about someone else, I should hope. You’ve been put on notice.

        1. Angry and sad at myself. For not being a good enough citizen. For not paying enough in taxes so that the VA budget could be increased.

          THAT kind of angry and sad.

          Of course….

          I think Ima go fire up my woodchipper and get so of this anger out. On the apple tree branches I have piled up. Of course.

  4. A successful suicide means one less patient with depression.

  5. The VA is currently researching ways to retaliate against the GAO.

    1. The VA is currently researching ways to retaliate against the GAO.

      That would not go well for the VA.

  6. I keep reading that 2Chilly is leaving. Did I miss something? Because if he is truly leaving, I am gong to have a sad.

    1. He snuck that announcement in at the end of one of his posts, recently. He wants to spend more time with his family.

      1. Thanks.

        I am not happy about him leaving. So unhappy, I am going to go buy power tools and write a strongly worded letter about The Article That Can Not Be Named; The Article That Must Not Be Named.

  7. My classmate’s step-aunt makes $61 hour on the internet . She has been fired from work for nine months but last month her pay check was $12801 just working on the internet for a few hours. try this out.

  8. Government-run health care, y’all.

  9. Well, if the suicidal veterans kill themselves because they didn’t recieve proper care, than the VA doesn’t have to spend any money treating them. So they save money up front by not treating them, and then they save more money when they off themselves. Sounds like a win-win… if you’re a sociopath.

    Just wait until the tardos get their wish and finally push through single payer. It’ll be VA healthcare for everyone. Except for “the rich” of course, who will be able to afford to pay cash under the table for their own private docs.

  10. I applaud Brandon and everyone involved. They risk their jobs and reputation to make changes in this insane system of mental and medical healthcare.
    As you celebrate this victory and vindication, it is now time to broaden your spotlight on this very difficult problem.
    The DOD mental health system is also a shameful farce. Commanders can override mental health diagnosis ,and treatment is sparse and disconnected, due to constant changes in an active duty service-members career. The DOD has the best doctors in the world to diagnose and treat mental health issues, but getting to one, and having the ability to get treatment, is rare.
    My son was criminalized instead of treated, even though he had a prior PTSD diagnosis, and was seeking care for depression just weeks after deployment #3. He attempted suicide the day after he went in the brig. The military didn’t list him as an attempted suicide due to PTSD, they listed his attempt as “a failure to adapt to the brig”.
    Appropriate and thorough mental health identification, treatment, and suicide prevention should begin in active duty and continue through VA ? but they do not!
    Our service-members deserve better. Thank God for men like Brandon who are willing to fight for better care!!

  11. Isn’t volunteering to serve the government prima facie evidence of mental illness?

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