The U.S. Department of Veterans Affairs provides inconsistent treatment to veterans with depression and may be underestimating the number of vets who suffer from the condition, according to a government watchdog agency.
The VA also needs to do a better job monitoring veterans who are prescribed antidepressants and in tracking suicides, according to a new report by the U.S. Government Accountability Office.
The GAO analyzed VA data from the 2009 through 2013 fiscal years and found inconsistencies in the way veterans were treated and medical records were kept. It also found that the VA’s own clinical guidelines were not always followed.
VA officials did not respond to requests for comment about the report. The GAO is an independent, nonpartisan watchdog agency that works for Congress and investigates how the federal government spends taxpayer dollars.
According to the GAO, from 2009 through 2013 about 10 percent of veterans – or 532,222 individuals – who sought health-care services through the VA were diagnosed with major depressive disorder. Symptoms include depressed mood, loss of interest or other conditions that last for two weeks or more and affect the patient’s ability to function.
But those figures may not accurately reflect the prevalence of depression among veterans, according to the GAO, because a sample of veterans’ medical records found diagnostic coding discrepancies in more than one third of the cases.
The GAO reviewed 30 individuals’ records and found coding errors in 11 cases. In each of those cases, there was at least one time a doctor documented a veteran having major depressive disorder in the record but did not code it properly. Instead, the doctor coded it as a less-specific depression, meaning those individuals were not flagged as having major depressive disorder.
Since VA data collection is tied to the diagnostic codes assigned by clinicians, improper coding can skew figures, according to the GAO.
Of those diagnosed with major depressive disorder, the vast majority – 94 percent, or 499,000 veterans – were prescribed at least one antidepressant, according to the GAO report.
But the GAO examined the records of 30 veterans who were given antidepressants and found that almost none were treated in accordance with the VA’s clinical guidelines for major depressive disorder.
In 26 of the 30 cases the GAO examined, veterans were not assessed using a standardized assessment tool, which guidelines stipulate should be used four to six weeks after a patient begins treatment. Also, guidelines say all veterans should be taught how to take their medication, but the GAO found no documentation of patient education in six of the 30 cases it examined.
The report also says “VA Central Office mental health officials were unable to tell us what it means to provide care that is consistent with the (guidelines).”
The guidelines are intended to “reduce practice variation and help improve patient outcomes,” but the VA can’t ensure that is happening without a clear understanding of how patients’ care matches up to the guidelines, the GAO report says.
“This report is extremely troubling and deeply disturbing because it confirms the anecdotal evidence about inadequacies,” said U.S. Sen. Richard Blumenthal, ranking Democrat on the Senate Committee on Veterans’ Affairs. “Discrepancies and other inconsistencies and inaccuracies in records is completely unacceptable.”
Cases of depression and suicide among veterans is “a spreading scourge” that needs to be addressed, he said.
Depression is more prevalent among veterans than it is among the general population, according to the VA and the GAO.
Depression in veterans disproportionately affects men, with data showing 87 percent of those with major depressive order from 2009 through 2013 were male veterans. The disorder also was most prevalent among whites, veterans between the ages of 35 and 64, and those who aren’t veterans of the recent conflicts in Iraq and Afghanistan, according to the report.
The GAO also found the VA keeps inaccurate data pertaining to veteran suicides. The agency reviewed 63 cases and found various mistakes: six cases listed an incorrect date of death, medical records in nine cases listed an incorrect number of outpatient VA mental health visits, and medical assessments were not performed uniformly, for instance.
The VA has taken steps to address depression and suicide among veterans, including the 2007 launch of a Veterans Crisis Line. In fiscal year 2013 alone, the crisis line received about 287,000 calls, 54,800 online chats and 11,300 text messages, according to the GAO.
But more needs to be done, Blumenthal said. He introduced legislation during the just-ended session of Congress that, among other provisions, would have created an evaluation process for mental health and suicide prevention services at the VA as well as the U.S. Department of Defense.
Though the legislation had widespread bipartisan support, it was blocked earlier this week by U.S. Sen. Tom Coburn, R-Okla., who is retiring this year for health reasons.
Blumenthal said he was saddened by the bill’s defeat but he plans to introduce it as his first piece of legislation when the new congressional session begins in January.
“I will fight for it,” he said, adding he also will continue to push for “very active and aggressive” oversight of the VA by the Committee on Veterans’ Affairs.