How the VA Cooked the Suicide Books

After two years in the Navy, spent in part working on an aircraft carrier, Luke had been diagnosed as bipolar. Despite his mental illness and struggles with alcohol, the young veteran was trying to pull his life together, his father tells National Review Online. But when Luke desperately sought help from the VA, the psychiatrist spoke harshly to him, set an appointment two weeks out, and sent the Senescalls on their way, Steve says.

Speaking quickly and furiously, Steve continues: “If you can imagine someone coming in to the emergency room with a compound fracture and a bone sticking out of their leg or arm, and the doctor says, ‘What are you doing here bothering me? You don’t have an appointment. Come back and make an appointment; come back, and I’ll take care of you.’ This boy was broken and crying in front of [the VA’s psychiatrist], and he didn’t even bother to want to take the time to help [Luke].”

Luke, still distressed, went on a walk, and VA records show that he again reached out to the medical center by phone, speaking briefly to a nurse practitioner and stating that he was “not okay.” As the night settled in, Steve and his family couldn’t reach Luke, and they began calling hospitals and jails. Finally, Jake — the big brother and fellow Navy man whom Luke adored and emulated — went to Luke’s house.

Steve says a friend who was with Jake at Luke’s house “saw the garage door open, and he goes, ‘Oh no,’ because the garage door is never open. And he walked into the garage, and there was my son. And he came out, and he yelled out at Jake, yelled, ‘Call 911!’ And Jake ran past him as he said, ‘No, don’t go in there!’ and Jake goes in there anyway, and he finds him. He grabs him, but Luke had already passed. And that was very disturbing for my son – very, very disturbing.” On July 7, 2008 — about three hours after unsuccessfully seeking in-person help at the VA medical center — Luke had hanged himself with an extension cord.

As the VA scandal continues to make headlines, the media has paid much attention to the long wait times and their effects on veterans’ physical health, as well as to the efforts of VA employees to cover up their shortcomings.

But the VA has also repeatedly failed to provide prompt and adequate mental-health services to veterans. Furthermore, records dating back as far as 2008 call into question whether the VA has tried to cover up veteran suicides and game the numbers for the scheduling of mental-health services.

To be sure, in any individual instance, it’s unclear whether poor performance at the VA resulted in a suicide that would otherwise have been prevented. Nonetheless, the statistics on veteran suicides are staggering: Though veterans are 13 percent of the total U.S. population, they account for around 20 percent of the nation’s suicide deaths. In February 2013, the VA estimated that 22 veterans commit suicide each day — one in five of whom are enrolled in the VA’s health-care system. 

“The health and well-being of the men and women who have served in uniform is the highest priority for VA,” a VA spokesperson told NRO. “We have made strong progress, but we must do more. Every Veteran suicide is a tragic outcome and regardless of the numbers or rates, even one Veteran suicide is one too many. VA is committed to ensuring the safety of our Veterans, especially when they are in crisis.”

The VA has taken some steps to address the veteran-suicide crisis: Since President Obama took office, the VA’s mental-health spending has increased by nearly 55 percent, rising to $6.969 billion in 2014. Obama also signed an executive order in 2012 that included the creation of Veterans Crisis Line, which the VA says has saved more than 37,000 veterans in crisis. The VA has also begun an effort to partner with community non-VA mental-health providers, especially in rural communities, and to fill some of the vacant mental-health positions.

Nevertheless, there’s significant room for improvement, says Jacqueline Maffucci, the research director at the Iraq and Afghanistan Veterans of America (IAVA). “Our members tell us that they’re satisfied with their care when they can get in the door, but getting in the door is the hardest part,” she says. “IAVA has real questions about whether the VA understands the physical and mental-health-care demands of today’s vets and has asked for the resources to meet those demands.” 

The VA is still struggling to overcome years of mismanagement, delays, and data inconsistencies that can be interpreted as incompetence at best and a deliberate cover-up at worst.

Concern about the VA’s handling of mental health became a hot topic in 2007, when CBS News conducted a five-month, 45-state investigative project that examined veteran suicides during 2005. Its reporters discovered that veterans were “more than twice as likely to commit suicide . . . than non-veterans.” Overall, it found 6,256 veteran suicides in 2005 — or 120 a week.

Those numbers contrasted starkly with the statistics the VA reported: It was claiming only 790 veterans had committed suicide in 2007. In fact, the VA’s head of mental health, Ira Katz, told CBS at the time that “there is no epidemic in suicide in the VA,” and when the story was published, he criticized CBS’s statistics on veteran suicide in 2005 as “not, in fact, an accurate reflection of the rate.”

Internal VA correspondence told a different story, though. In an e-mail Katz titled “Not for the CBS Interview Request,” he wrote: “Shh! Our suicide prevention coordinators are identifying about 1,000 suicide attempts per month among veterans we see in our medical facilities. Is this something we should (carefully) address ourselves in some sort of release before someone stumbles on it?” In another e-mail, Katz wrote that around 18 veterans a day — or 6,570 a year — commit suicide, a number roughly in line with the CBS report. Moreover, he wrote, “VA’s own data demonstrate 4–5 suicides per day among those who receive care from us.”

The e-mails prompted calls for Katz’s resignation at the time, but records from the Office of Personnel Management show that Katz has continued to work in Philadelphia in mental health at the Veterans Health Administration (VHA). In fact, between 2010 and 2013, he earned $1.06 million. Multiple government publications from 2012 list him as a senior consultant for the VA’s Office of Mental Health Services, and the New York State Office of Mental Health cited him in 2014 as the man who “oversees mental health programs at the Department of Veterans Affairs.” He has also since worked as the VA’s co-chairman on a working group for the assessment and management of risk for suicide.

A VA spokesperson did not reply to questions about Katz by NRO’s deadline.

Other statistical errors have abounded, including at the Spokane VA, where Luke Senescall was sent home on the day of his death. Between July 2007 and July 2008, the Spokane VA reported nine suicides and 34 suicide attempts. But the VA’s Office of Medical Investigations later discovered that at least 21 veterans had killed themselves in the region that year and that two-thirds had been in contact with the Spokane VA before their deaths. Within that 2007–08 date range, the director of Spokane’s Veterans Affairs facility was Sharon Hellman — who went on to manage the Phoenix VA system, where as many as 40 veterans were put on a secret wait list and reportedly died.

The VA did not respond to a question about whether the underreporting of suicide statistics in Spokane was an error or a cover-up, but Steve Senescall speculates that Hellman “took her practices from what she was doing here [in Spokane] down there [to Phoenix], and it finally caught up with her.”

The Spokane VA has been plagued with problems ever since. In July 2009, a year after Luke Senescall’s suicide, the facility’s four psychiatrists and one nurse practitioner refused to take new patients, citing a heavy caseload. The same year, the Spokesman-Review wrote of patients who had waited three months or more for a half-hour psychiatric appointment. And in 2011, the Spokesman-Reviewreported that for every mental-health professional there were between 550 and 650 veterans seeking mental-health treatment.

Problems with mental-health services are not limited to isolated regional facilities but are spread throughout the VA system, a 2012 report by the VA Office of the Inspector General suggests. Its investigators discovered that the Veterans Health Administration was essentially gaming the numbers to report more timely scheduling of mental-health services than had actually occurred. It bashed the VHA for “[lacking] a reliable and accurate method of determining whether they are providing patients timely access to mental health care services.”

At the time, the VA was claiming that 95 percent of first-time patients at VHA had received a full mental-health evaluation in 14 days. But in reality, the investigators found, more than half of these first-time veteran patients were waiting, on average, 50 days.

A VA spokesperson did not respond to NRO’s questions about this 2012 report. But other sources and articles note that delays in mental-health treatment for veterans have been attributed to multiple factors, including everything from a shortage of professionals to treat them to an increase in the number of veterans after the Iraq and Afghanistan wars to backlogs in the processing of mental-health-based disability claims.

Regardless of the reasons for delays, waiting for mental-health services at the VA can be a grueling endeavor, as Paula Brown-Nichols of Waxahachie, Texas, knows all too well. “I divorced when Cory was three, and it was he and I against the world,” she tells NRO. “He had never really been away from me other than a weekend with his dad . . . until he went to boot camp.”

Paula describes her son as “Mr. Personality-Charisma,” describing how he had graduated from high school a year early. His father and maternal grandfather were both military, and when Cory turned 18, he followed in their vocation, enlisting with the National Guard. Soon after his training had finished, Cory was shipped off to Camp Taji, Iraq. He bought an Iraqi phone, and he’d call his mother every day except for those he was sent out on missions.

During Cory’s two-week break home, he took his mother to see The Lion King in Dallas, but when he walked into the theater, “there were a lot of kids, and they were clapping and singing in the foyer before it started, and his face turned beet red, and his eyes were just going crazy back and forth and looking over and back, and he had a panic attack. All of a sudden, he could not breathe. He monkey-crawled from the foyer. . . . We got outside, and he was having a hard time breathing. . . . That was my first clue that something was going on.”

Cory returned to Iraq, finished his tour, and headed home, bringing a post-traumatic-stress-disorder (PTSD) diagnosis with him. The veteran’s grandmother was having heart surgery, so Cory missed the transitional counseling the military provides, Paula says. While Cory kept up appearances for the first few months, his mental health was quickly deteriorating, and he began self-medicating with drugs, she says.

Paula began pushing the VA to treat her son for PTSD and substance abuse, but she says she could only get him into short-term detox, where he was admitted for less than a week. His doctors changed repeatedly, she says, and one even prescribed Xanax, even though Paula had informed them that “it was his drug of choice” to abuse. The Associated Press has reported that Cory also saw a VA counselor once a month.

Paula says what her son really needed was a 30-to-90-day intensive-treatment program, but the VA repeatedly told her there were no beds available. Cory could call each day to see if a bed had opened up, she says, but the responsibility to check in daily was his, and the VA had also cautioned that if he relapsed, the process would start over again entirely.  

Finally, one night in September 2011, Cory got into an argument with his wife, whom he had married just months before after finding out she was pregnant. The police were called, and Cory was briefly handcuffed as his wife left the premises. Sitting on his lawn by a tree, “he was begging her not to leave, saying he’d kill himself if she left,” Paula says. Cory called his mother, who tried to calm him down.

Eventually, “I thought he was okay,” Paula recalls. “The next morning, I couldn’t get him on the phone. I’d usually talk to him every morning.” Concerned, she called her ex-husband, who also attempted to reach him by phone, and then drove to his house. “My ex-husband found him,” she says. “He had shot himself in the head, they said, between 12:30 and 2 a.m. . . . They say he died immediately, and I want to believe that.”

Today, Paula has custody of Cory’s son, “my angel boy. He looks like my son, and he definitely acts like him.” But despite that consolation, she deeply grieves. She has never washed his uniform, and she wonders what would have happened if Cory’s psychiatrist had been more available, or if the police had taken his suicide threats seriously that night.

But most of all, she says, she holds the VA accountable for its failure to provide her son with the mental-health services he needed. “If the VA had put him in long-term treatment,” Paula says, “we might not be having this conversation. But you just can’t get in — you can’t get in. . . . The VA has got to make some changes. They’re killing our vets.”

— Jillian Kay Melchior is a Thomas L. Rhodes Fellow for the Franklin Center for Government and Public Integrity. She is also a senior fellow at the Independent Women’s Forum.