How the VA Cooked the Suicide Books
The agency hides long waits for veterans in mental-health crises.

Spokane Veterans Affairs Medical Center (Facebook)


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-Review reported 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.


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