VA Mental Health: VHA Improved Certain Prescribing Practices, but Needs to Strengthen Treatment Plan Oversight

In fiscal year 2018, of the roughly 6 million veterans who received services from VHA, approximately 2 million had a diagnosis for at least one mental health condition. Treatments for such mental health conditions can include psychotropic medications or non-pharmacologic therapies, which can be prescribed or offered by VA providers in outpatient settings including primary and specialty care.

GAO was asked to review how mental health treatment decisions are made by providers in VAMCs and monitored by VHA. This report examines, among other things, (1) factors that contribute to providers' treatment decisions for veterans with mental health conditions, (2) VHA's guidance for documenting mental health treatment plans, (3) VHA's monitoring of whether providers document their consideration of different treatment options, and (4) VHA's efforts to improve the treatment of veterans prescribed psychotropic medications. GAO reviewed VHA documents and a nongeneralizable sample of veterans' medical records from five VAMCs (selected for variety in facility complexity and location); analyzed data on psychotropic medication prescribing; and interviewed VHA and VAMC officials.

Officials from the five selected Department of Veterans Affairs (VA) medical centers (VAMC) GAO spoke with reported various factors that contribute to providers' mental health treatment decisions, including decisions regarding the prescribing of psychotropic medications and the offering of non-pharmacologic therapy. Examples of reported factors include: VAMC resources, such as the availability of appointments with mental health providers in specialty care, and the complexity of veterans' mental health conditions, such as the veterans' diagnoses and treatment history.

Officials with VA's Veterans Health Administration (VHA) told GAO that specialty mental health care providers are expected to document mental health treatment plans in an easily identifiable way in veterans' medical records, but VHA has not developed guidance explicitly addressing this expectation. For example, VHA's mental health services handbook requires that treatment plans include certain components, but does not specify where to document the plan within a veteran's medical record. As a result, there is a risk that a provider may be unable to readily access information about a veteran's mental health treatment, including the use of medication or therapy, during changes in a veteran's care.

VHA has not monitored whether mental health providers in specialty care document the required consideration of different treatment options—such as psychotropic medications or non-pharmacologic therapy—within mental health treatment plans. VHA officials told GAO that VHA relies on the Joint Commission (an independent, not-for-profit organization that accredits and certifies health care organizations) to assess specialty mental health treatment plans as part of the organization's accreditation process for each VAMC. However, the Joint Commission's standards do not specifically assess whether providers consider different treatment options. As a result, VHA cannot ensure that providers are considering all available treatment options and providing the most appropriate treatments to each veteran.

VHA has taken steps to improve veterans' mental health treatment through the Psychotropic Drug Safety Initiative (PDSI)—an initiative focused on the safe and effective prescribing of certain psychotropic medications. For example, the first phase included a performance metric aimed at decreasing the percentage of veterans with post-traumatic stress disorder receiving one or more outpatient prescriptions for a benzodiazepine (a medication used to treat anxiety) because of risks associated with the medication. VHA reported a nationwide 5.4 percentage point decrease in the prescribing of this medication for these patients, as well as improvements in the majority of the initiative's other performance metrics.

VHA should (1) disseminate guidance reflecting its expectation that providers document mental health treatment plans in an easily identifiable way, and (2) implement an approach for monitoring whether these treatment plans include consideration of treatment options. VHA agreed with GAO's recommendations.

In fiscal year 2018, about 2 million veterans who received health care  from the Department of Veterans Affairs (VA) had at least one diagnosed  mental health condition. Certain mental health conditions, such as major  depressive disorder (MDD) and post-traumatic stress disorder (PTSD),  are highly prevalent among veterans. Methods of treatment vary; for  some veterans, psychotropic medications may be the safest and most  effective method of treatment, while specific forms of non-pharmacologic  therapy in lieu of, or in addition to, these medications may work better for  others. If conditions are left untreated or if treatment is unsuccessful,  some veterans may experience serious consequences; for example,  unresolved PTSD may lead to substance abuse, depression, or suicide.  These serious consequences underscore the importance of providers’  mental health treatment decisions for veterans.

Veterans may be treated in outpatient settings at VA medical centers  (VAMC), including in primary and specialty care. In recent years, the  Veterans Health Administration (VHA) has aimed to increase the role of  primary care and mental health providers in the primary care setting in  making mental health treatment decisions, so that treatment can begin as  early as possible. These providers may decide to prescribe psychotropic  medications or offer non-pharmacologic therapy, among other things. The  primary care setting is also advantageous, as veterans assessed there  are concurrently screened for risk for suicide, a persistent and growing  public health problem for the United States and its veterans, particularly  those with mental health conditions. According to VHA, an average of 20  veterans die by suicide each day, and approximately 75 percent of those  veterans each had at least one mental health condition recorded in their  medical records in the 5 years prior to their deaths.

You asked us to review how treatment decisions are being made by  VAMC providers across outpatient settings and how those decisions are  monitored by VHA. In this report, we examine:  1.  the factors that have contributed to providers’ treatment decisions for  veterans with mental health conditions;  2.  the extent to which VHA has developed guidance for the  documentation of mental health treatment plans in veterans’ medical  records;  3.  the extent to which VHA has monitored providers’ documentation of  treatment option considerations for veterans with mental health  conditions;  4.  the extent to which VHA has taken steps to improve the treatment of  veterans with mental health conditions who are prescribed  psychotropic medications; and  5.  the extent to which VHA has included the treatment of mental health  conditions with psychotropic medications in its efforts to examine  suicide risk among veterans.

To examine the first three objectives, we interviewed officials involved in  veterans’ mental health treatment from five VAMCs and their four  associated Veterans Integrated Service Networks (VISN), VHA’s regional  networks of care, and we reviewed a random, nongeneralizable sample of  veterans’ medical records. Specifically, we interviewed providers who  work in outpatient care settings, including primary care providers (PCP),  mental health providers in specialty care (e.g., psychiatrists), and clinical  pharmacy specialists. We selected the five VAMCs for variation in (1) the  percentage of veterans who were seen by any provider at the VAMC for a  mental health diagnosis and received at least one psychotropic  medication prescription in fiscal year 2017 (the most recent year for which  data were available), (2) facility complexity level, and (3) geographic  location. See table 1 for a list of the five VAMCs we selected and their  four associated VISNs. Perspectives obtained from these VAMCs and  VISNs cannot be generalized.

We reviewed a random, nongeneralizable sample of medical records for  150 veterans with MDD, PTSD, or generalized anxiety disorder (GAD)  (the three most prevalent mental health conditions among veterans) who  received outpatient mental health care services in fiscal year 2017 from  the five VAMCs within our review. The sample included two groups of  randomly selected medical records: (1) 75 veterans, each of whom had a  primary care visit, and were prescribed a new psychotropic medication,  and (2) 75 veterans, each of whom had a mental health visit in an  outpatient setting and who may or may not have been offered non- pharmacologic therapy. Across these two groups of veterans, 80 had a  visit with a mental health provider in specialty care and were prescribed a  psychotropic medication; we reviewed their medical records to examine  how mental health providers document treatment decisions. Examples  provided from our review of veterans’ medical records cannot be  generalized to the five selected VAMCs.

We took additional steps to specifically address each objective. For the  first objective, to describe the factors that contributed to providers’  treatment decisions for veterans with mental health conditions, we  interviewed officials at the five selected VAMCs and reviewed  documentation VAMC providers may use when making treatment  decisions. In our interviews with officials, we asked about factors that  contributed to PCPs’ decisions to prescribe psychotropic medications to  veterans before or without referring veterans to mental health providers in  specialty care. We also asked about factors that contributed to providers’  decisions to offer non-pharmacologic therapy to veterans in lieu of, or in  addition to, prescribing psychotropic medications. We then identified  factors that were reported by officials at multiple VAMCs. During our  interviews, 52 PCPs and mental health providers in specialty care  completed questionnaires so we could obtain their perspectives on how  frequently certain treatment decisions were made by providers within their  VAMCs. We also reviewed documents developed by VHA and VAMC  officials, such as guidance for providers to consider when treating  veterans with mental health conditions. For context, we obtained data  from VHA related to the pharmacologic and non-pharmacologic treatment  of veterans with mental health conditions for fiscal year 2018. We  analyzed these data to determine the specific outpatient care settings in  which veterans with different numbers and types of mental health  conditions were seen, as well as the types of treatment that were  provided to these veterans.

For the second objective, to examine the extent to which VHA has  developed guidance for the documentation of mental health treatment  plans in veterans’ medical records, we reviewed VHA documentation,  such as VHA’s Health Information Management and Health Records  handbook. We also interviewed VHA officials from the Office of Mental  Health and Suicide Prevention and the Office of Health Informatics, as  well as officials at our five selected VAMCs, regarding the documentation  of veterans’ mental health treatment plans. Additionally, we interviewed  officials from the Joint Commission, the organization responsible for  accrediting and certifying VAMCs and other health care facilities. We then  compared VHA’s issued guidance with federal internal control standards  related to control activities, risk assessment, and information and  communication.

For the third objective, to examine the extent to which VHA has monitored  providers’ documentation of treatment option considerations for veterans  with mental health conditions, we reviewed VHA documentation, such as  VHA’s Uniform Mental Health Services in VA Medical Centers and Clinics  handbook. We interviewed VHA officials from the Office of Mental Health  and Suicide Prevention, as well officials at our five selected VAMCs,  regarding documentation of these considerations. We also interviewed  officials from the Joint Commission about its standards related to such  documentation. We then compared VHA’s monitoring efforts for mental  health treatment planning with federal internal control standards related to  monitoring.

For the fourth objective, to describe the extent to which VHA has taken  steps to improve the treatment of veterans with mental health conditions  who are prescribed psychotropic medications, we reviewed VHA  documentation, such as VHA program manuals related to initiatives to  improve the prescribing of psychotropic medications and evaluation  reports documenting the outcomes of relevant VHA programs. We also  interviewed VHA officials, including those from the Office of Mental Health  and Suicide Prevention and Pharmacy Benefits Management Services,  as well as officials at the four VISNs associated with our five selected  VAMCs, regarding national and local roles and responsibilities related to  improving the safety and effectiveness of prescribing psychotropic  medications. We also obtained data from VHA on national prescribing  rates for certain psychotropic medications.

For the fifth objective, to describe the extent to which VHA has included  the treatment of mental health conditions with psychotropic medications in  its efforts to examine suicide risk among veterans, we reviewed relevant  VHA documentation, including reports and presentations (such as public  webinars) from relevant VHA programs, as well as publications and other  documents (such as draft manuscripts) related to ongoing and completed  research studies. We interviewed officials from VHA’s Office of Research  and Development and Office of Mental Health and Suicide Prevention  about relevant efforts, as well as VHA officials from the following VHA  research centers: (1) the Serious Mental Illness Treatment Research and  Evaluation Center; (2) the VISN 2 Center of Excellence for Suicide  Prevention; and (3) the Rocky Mountain Mental Illness Research,  Education, and Clinical Center for Veteran Suicide Prevention. In our  discussions with VHA officials, we also obtained information related to  advantages and challenges that may impact VHA’s ability to include the  use of psychotropic medications as a factor when examining suicide risk.

We conducted this performance audit from November 2017 to June 2019  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.

About 2 million of the more than 6 million veterans who received VHA  services in fiscal year 2018 had at least one diagnosed mental health  condition, with MDD being the most prevalent diagnosis. About half of  these approximate 2 million veterans had a single mental health condition  while the remaining half had multiple mental health conditions (see fig. 1).

In fiscal year 2018, the three most prevalent mental health conditions  among veterans using VHA services were MDD (15 percent), PTSD (12  percent), and GAD (3 percent):

MDD. This condition is the most prevalent and disabling form of  depression. In addition to the immediate depression symptoms (such  as persistently feeling sad or anxious, loss of interest in activities, and  difficulty sleeping or oversleeping), MDD can result in poor quality of  life overall and decreased productivity, and increased risk of suicide.

PTSD. Those with PTSD have experienced symptoms that have  persisted for more than 1 month after exposure to a traumatic event,  although the onset of symptoms may be delayed for much longer, and  cause significant distress or impairment in social, occupational, or  other important areas of functioning. Symptoms may include  recurrent, involuntary memories of the traumatic event and flashbacks  in which the veteran feels or acts as if the traumatic event were  recurring. PTSD is strongly associated with reduced quality of life and  adverse physical health outcomes.

GAD. Those with GAD feel continually worried or anxious about a  range of events or activities in their daily lives and have difficulty  controlling or stopping this worry. Along with feeling worried, those  with GAD experience symptoms of tension such as restlessness,  feeling on edge, being easily tired, difficulty concentrating, and sleep  difficulties.

Veterans with mental health conditions may be offered a variety of  treatment options. Of the approximate 2 million veterans with at least one  diagnosed mental health condition in fiscal year 2018, 45 percent  received non-pharmacologic therapy, 27 percent received a combination  of non-pharmacologic therapy and psychotropic medication, and 10  percent received psychotropic medication only.

Non-pharmacologic therapy. Non-pharmacologic therapy, or  psychotherapy, involves treating mental health conditions using  psychological rather than medical means. There are many different  types of therapy options, although not all may be available at every  VAMC. Examples of non-pharmacologic therapies include cognitive  behavioral therapy and prolonged exposure therapy. Some therapy  options may be provided to individual veterans, while others are  offered to groups of veterans.

Psychotropic medications. Psychotropic medications are used to  affect one’s mood, thought, or behaviors. Veterans can be prescribed  one or more psychotropic medications, from one or more classes, to  treat their diagnosed mental health conditions. For example,  sertraline—a psychotropic medication commonly known by its brand  name Zoloft®—is used by VHA providers to treat both depression and  anxiety.

Combining treatment. Providers may decide to offer both  psychotropic medications and non-pharmacologic therapy, rather than  prescribing or offering either option alone.

Decisions to offer any of these treatment options are made by providers  in various VAMC outpatient care settings.

Primary care setting. In addition to addressing other health care  needs, PCPs may order non-pharmacologic treatment, prescribe  psychotropic medications, or combine both treatment options to  address a veteran’s mental health conditions. Through the primary  care-mental health integration (PC-MHI) model, which VAMCs began  implementing in 2007, PCPs may also collaborate with mental health  providers (e.g., psychologists, social workers, nurses) who are  collocated within the primary care clinic before making treatment  decisions. These collocated mental health providers can also offer  non-pharmacologic therapy to veterans without requiring a separate  visit outside of primary care.

Specialty care setting. Mental health providers in a specialty care  setting, such as psychiatrists, decide whether to provide any type of  treatment for veterans who have been referred to them by providers in  primary care for services specific to their mental health conditions.  Veterans may also seek services from a mental health provider in  specialty care without first obtaining a referral from primary care.

Mental Health Treatment Planning Requirements

VHA has established certain requirements for providers’ documentation of  specialty mental health care treatment plans, and the Joint Commission  periodically reviews the documentation of such plans to ensure that they  align with the Commission’s standards.

VHA. To ensure that providers develop appropriate approaches to  treating veterans with mental health conditions and reevaluate such  treatment approaches over time, VHA has established certain policies  to govern the documentation of mental health treatment decisions by  mental health providers in specialty care. For example, in 2008, VHA  issued its mental health services handbook to define minimum clinical  requirements for mental health services at VAMCs, requiring that  providers in specialty care document mental health treatment plans in  veterans’ electronic medical records. The mental health services  handbook specifies that plans should include certain components  such as documentation that different evidence-based treatment  options were considered by mental health providers and that  approaches to monitor the outcomes of care were developed.

The Joint Commission. The Joint Commission is an independent,  not-for-profit organization responsible for accrediting and certifying  health care organizations and programs in the United States  (including VAMCs) at least once every 3 years, and it has developed  standards to use as the basis of its evaluative process. These  standards focus on specific patient and organization functions that are  essential to providing safe and high-quality care, including plans for  treatment provided in mental health care settings.

VAMC Resources and the Complexity of Veterans’ Mental Health Conditions Are among Factors That Contribute to Providers’ Treatment Decisions

VAMC officials we interviewed reported various factors as contributing to  providers’ decisions to prescribe psychotropic medications and offer non- pharmacologic therapy to veterans. Specifically, officials from multiple  VAMCs cited each of the following factors as contributing to treatment  decisions: VAMC resources, complexity of veterans’ mental health  conditions, comfort level of providers with treating conditions or  prescribing medications, veterans’ preferences, and logistics of receiving  mental health treatment. See table 2 for the factors and supporting  examples offered by VAMC officials during our site visits.

In our review of documentation VAMC providers may use when making  treatment decisions, we identified some additional factors. For example,  providers’ use of clinical practice guidelines (CPG) established by VA and  the Department of Defense may contribute to providers’ treatment  decisions. Specifically, the CPG for mental health conditions that are  highly prevalent among veterans, including MDD and PTSD, are a  resource that all VAMC providers may use when making treatment  decisions. For example, the CPG for the management of MDD  recommends that providers offer either psychotropic medications or non- pharmacologic therapies (such as behavioral therapy) for the primary  treatment of uncomplicated MDD. In contrast, the CPG for the  management of PTSD recommends initial treatment for this condition to  be a specific type of non-pharmacologic therapy (individual trauma- focused therapy), and when this therapy is not readily available or  preferred, then treatments include prescribing psychotropic medications  or offering another form of non-pharmacologic therapy. Though it is not  mandatory for providers to follow the recommendations of the CPGs,  which are based on the strength of evidence and also the potential  benefits and harms of treatment options, every provider is responsible for  evaluating the appropriateness of applying CPG recommendations in any  particular clinical situation.

Another factor we identified in our review of documentation was service  agreements that VAMCs have in place to help coordinate mental health  services across outpatient settings. All five of the VAMCs in our review  have formal agreements to help coordinate mental health services across  outpatient settings to help manage VAMC resources. These agreements  indicate that, for example, providers in primary care can provide treatment  for certain mental health conditions, such as uncomplicated depression,  without referring veterans to mental health providers in specialty care  (see text box).

Service Agreements between Primary and Specialty Care for the Treatment of  Mental Health Conditions in Selected VA Medical Centers (VAMC)  All five of the VAMCs in our review have formal service agreements to help coordinate  treatment across primary and specialty care settings for certain mental health  conditions, such as uncomplicated depression:  All service agreements from the VAMCs in our review indicated that providers in  primary care can treat uncomplicated depression without referring veterans to a  mental health provider in a specialty care setting.  All service agreements indicated at what point mental health providers in specialty  care should be involved to help treat veterans with uncomplicated depression—for  example, if veterans failed to respond to treatment after trying two different  psychotropic medications, or if symptoms worsen over time.

In addition to uncomplicated depression, other mental health conditions (including  anxiety, PTSD, schizophrenia, and bipolar disorder) were addressed in four of the five  service agreements we reviewed. For example, the four service agreements indicated  that veterans with bipolar disorder should be treated by mental health providers in  specialty care.

In light of these factors, providers we interviewed reported on the extent  to which each of the most prevalent mental health conditions resulted in  PCPs prescribing medication to veterans prior to or without being referred  to specialty care. Specifically, more providers reported that psychotropic  medications are commonly prescribed to veterans with MDD, PTSD, or  GAD prior to referring them to specialty care compared to providers who  reported that it is common to prescribe without referring veterans to  specialty care at all. See figure 2 for the percentages of providers  reporting that psychotropic medications are commonly prescribed to  veterans with these three conditions prior to referring them to specialty  care.

Providers also reported on the extent to which it was common for any  provider to offer non-pharmacologic therapy to veterans with these three  conditions in lieu of, or in addition to, prescribing psychotropic  medications. More providers reported that non-pharmacologic therapy is  commonly offered in addition to psychotropic medications compared to  providers who reported that it is common to offer therapy instead of  medication. See figure 3 for the percentages of providers reporting that  non-pharmacologic therapy is commonly offered in addition to  psychotropic medications.

See appendix I for additional information about mental health treatment  practices, including the prescribing of psychotropic medications and  offering non-pharmacologic therapy to veterans in a random,  nongeneralizable selection of medical records from the VAMCs in our  review. See appendix II for information on the use of psychotropic  medications or non-pharmacologic therapy by VHA providers to treat  veterans with certain mental health conditions, nationally, in fiscal year  2018.

VHA Has Not Developed Guidance that Communicates Its Expectation That Mental Health Treatment Plans Be Easily Identifiable

VHA has not developed and disseminated guidance that specifies its  expectation that mental health providers in specialty care document  treatment plans in an easily identifiable way within veterans’ medical  records. According to VHA officials responsible for overseeing mental  health services, mental health providers should be documenting  treatment plans in notes that are easily identifiable and separate from  other health information, rather than embedding the plans in progress  notes where they may combined with other information related to  veterans’ medical histories and current health conditions. In our  nongeneralizable review of 80 medical records for veterans who were  seen by providers in specialty care and prescribed a psychotropic  medication, we found that a majority (50) had a mental health treatment  plan recorded in a progress note. We viewed several examples where the  treatment plan was not the only information recorded within the progress  note, making it difficult to readily identify the mental health treatment plan  itself.

A VHA official responsible for overseeing mental health services told us it  is important for a mental health provider in specialty care to document  each veteran’s treatment plan in such a manner so that the provider, or  any other providers who may become involved in the veteran’s treatment,  can readily refer to the plan as they evaluate progress. This may be  particularly important during transitions between inpatient and outpatient  care settings, or when adding providers to a veteran’s care team.  Providers need to be able to readily access veterans’ mental health  treatment plans to ensure that treatment is being provided as ordered,  understand why certain treatments were decided against, and assess  whether treatment changes are needed. The same VHA official told us  that he encourages this practice to support VAMC compliance with the  Joint Commission’s standards for mental health treatment plans.

However, relevant VHA guidance documents for mental health providers  do not specify this expectation:

VHA mental health services handbook. The VHA mental health  services handbook, published in 2008, requires that mental health  providers in specialty care document treatment plans that include  certain components. However, it does not specify where providers  should document such plans within veterans’ medical records.

VHA memo. A 2012 VHA memo promotes the use of a software  program by mental health providers in specialty care that, according  to VHA officials, facilitates the documentation of treatment plans in  notes that are easily identifiable and separate from other information.  However, the memo did not specifically state that documenting  treatment plans in easily identifiable and separate locations from other  information is the goal of using the software program, nor does the  memo require providers to use the software.

VHA health records handbook. This handbook, published in 2015,  provides basic health information procedures for managing veterans’  health records and specifies that all outpatient providers must include  treatment plans in progress notes. It does not explicitly reflect VHA’s  expectation for mental health providers in specialty care to document  mental health treatment plans in an easily identifiable way. Further,  the health records handbook specifies that progress notes must also  include other types of information, including the history of the  veteran’s medical problem, the provider’s assessment of the problem,  any tests or consults ordered, and instructions given to the veteran.

VHA officials did not provide a rationale as to why they have not  developed guidance that clearly directs mental health providers in  specialty care to document treatment plans in an easily identifiable way  within veterans’ medical records. They noted that VHA has relied upon  the VAMCs to develop local processes for documenting specialty mental  health treatment plans in an easily identifiable way when providers decide  not to use the software program that VHA promoted in its 2012 memo.  According to VHA officials, VHA is developing a new memo to  communicate its expectation that mental health providers in specialty care  document treatment plans in an easily identifiable way within veterans’  medical records. However, as of March 2019, VHA officials had not  finalized this memo or indicated when the memo will be disseminated.  Standards for internal control in the federal government require that  agencies document responsibilities through policies and define objectives  in terms that are understood at all levels. These standards also require  that agencies communicate necessary information throughout all agency  reporting lines to achieve the agencies’ objectives. Absent VHA  guidance that clearly identifies its expectation for documenting specialty  mental health treatment plans, providers may incorrectly record treatment  plans in veteran’s electronic medical records such that they are not easily  identifiable. As a result, there is a risk that a provider may be unable to  readily access important information about a veteran’s mental health  treatment, including the use of psychotropic medication or non- pharmacologic therapy, during changes in a veteran’s care.

VHA may learn of the extent of this risk through efforts to collect  information resulting from the Joint Commission’s accreditation survey  process. Specifically, VHA uses various conference calls to discuss the  Joint Commission accreditation survey process and results:

According to a VHA official, VHA has weekly and quarterly conference  calls with VISNs to, in part, help them prepare their VAMCs for future  surveys and, as a result, VHA may learn about different types of  citations that apply to multiple VAMCs. This, in turn, may allow VHA to  identify concerns that may need to be addressed system-wide,  including those related to mental health treatment planning.

The Joint Commission provides VHA with an annual summary of data  on common citations issued to VAMCs. According to the Joint  Commission officials, the Commission provides VHA with this  information through a conference call, which may also include a  discussion of the underlying causes for any trends in system-wide  citations. VHA officials may be able to use this information to address  any systemic problems related to the documentation of specialty  mental health treatment plans in an easily identifiable way within  veterans’ medical records.

According to a VHA official, VHA has not identified the documentation of  specialty mental health treatment plans as an area for improvement  across VAMCs. This issue was not included in the November and  December 2018 conference calls with the VISNs, nor was it included in  the 2018 annual summary of data that the Joint Commission provided to  VHA.

VHA Has Not Monitored Providers’ Documentation of Required Treatment Option Considerations in Mental Health Treatment Plans

VHA has not developed or implemented an approach for monitoring  whether mental health providers in specialty care are documenting their  consideration of different evidence-based treatment options in mental  health treatment plans as required by VHA’s mental health services  handbook. In our review of a nongeneralizable sample of 80 medical  records for veterans who were seen by such providers and prescribed a  psychotropic medication, we found that none of the veterans had  treatment plans that documented consideration of different evidence- based treatment options for the veterans’ mental health conditions.

VHA relies on the Joint Commission to assess mental health treatment  plans as part of the organization’s accreditation process for each VAMC,  according to VHA officials. However, VHA does not obtain information  resulting from the Joint Commission’s accreditation process that  specifically relates to whether mental health providers are documenting  consideration of different treatment options in their mental health  treatment plans as required. The Joint Commission’s accreditation  standards related to mental health treatment plans align with some, but  not all, of VHA’s mental health services handbook’s required treatment  plan components. For example, the standards align with VHA’s  requirement that mental health providers in specialty care must document  how they plan to track outcomes and re-evaluate treatment when needed.  However, they do not call for the Joint Commission’s accreditation survey  to assess whether specialty mental health treatment plans include  providers’ consideration of different treatment options, and, according to  organization officials, this is not something they look for when conducting  their reviews.

VHA’s mental health services handbook calls for monitoring through the  use of metrics to ensure implementation of the handbook’s requirements,  including those related to the documentation of the mental health  treatment plan components by mental health providers in specialty care.

Additionally, standards for internal control in the federal government  require that agencies establish appropriate performance measures for  defined objectives, perform ongoing monitoring activities, and remediate  identified deficiencies on a timely basis.

VHA’s lack of monitoring may contribute to inadequate documentation of  the treatment options considered by mental health providers in specialty  care in accordance with the mental health services handbook’s  requirements. As a result, VHA cannot ensure that mental health  providers in specialty care are appropriately considering all available  evidence-based treatment options to provide the best care for veterans.  This monitoring may be accomplished, for example, by establishing  metrics and monitoring performance against such metrics, as called for by  VHA’s mental health services handbook. Without metrics or other  approaches to monitoring, VHA officials may not be identifying and  addressing any systemic problems related to consideration of different  evidence-based treatment options.

VHA Has Taken Steps to Improve Veterans’ Treatment through the Psychotropic Drug Safety Initiative

VHA has reported improvement in the safe and effective prescribing of  certain psychotropic medications used to treat veterans with mental  health conditions since the 2013 start of its Psychotropic Drug Safety  Initiative (PDSI). To date, PDSI has consisted of three phases, with each  phase focusing on different classes or types of psychotropic medications,  age groups, or mental health conditions and substance use disorders.  PDSI is currently in phase 3 and VHA is in the process of planning for a  new phase 4, scheduled to begin in July 2019. For each phase, VHA  developed a set of performance metrics from which each VAMC was  required to select a designated number as a focus for implementing  prescribing-related quality improvement efforts (referred to as the VAMC’s  priority metrics). See table 3.

VHA reported improvements in the majority of the performance metrics  from the past PDSI phases. Specifically, VHA reported nationwide  improvements in 16 of the 20 metrics that it developed for phase 1, and  all 14 of the metrics that it developed for phase 2. For example, upon the  completion of phase 1, VHA found that there was a nationwide 5.4  percentage point decrease (indicating improvement on this metric) in the  percentage of veterans with PTSD who received one or more outpatient  prescriptions for a benzodiazepine (a type of antianxiety medication).  VHA reported that the change in benzodiazepine prescribing, among  other improvements in treating veterans with PTSD, was particularly  noteworthy given that the number of veterans diagnosed with this mental  health condition increased over the duration of phase 1. Further, upon the  completion of phase 2, VHA found that there was a nationwide 1.7  percentage point decrease (indicating improvement on this metric) in the  percentage of veterans 75 or older with an outpatient prescription for a  benzodiazepine or sedative hypnotic medication.

During each PDSI phase, VHA works with VISNs and VAMCs to support  their quality improvement efforts related to their priority metrics. For  example, VHA provides feedback and technical assistance to VISNs and VAMCs for  developing and implementing quality improvement strategies for their  priority metrics, which must be updated and submitted to VHA  semiannually;  convenes a bi-monthly PDSI conference call for VISN and VAMC staff  and providers involved in PDSI, which serves as a forum for providing  training to participants, discussing best practices, and facilitating  collaboration among VAMCs that may have chosen the same priority  metrics; develops a semi-annual feedback report for each VISN that includes,  among other content, the most recent quarterly score on the priority  performance metrics for each VAMC within the network, according to  a VHA official; and provides VISNs and VAMCs access to a PDSI clinical management  dashboard to use to identify veterans who may benefit from changes  to their psychotropic medication prescriptions. These lists can be  filtered by the care setting in which the patient is seen, such as the  primary or specialty care settings.

Although VISNs and VAMCs are not always required (but are  encouraged) to continue quality improvement efforts related to VAMCs’  priority metrics from past PDSI phases, VHA continues to monitor VAMC  performance on all metrics from each PDSI phase. Specifically, a VHA  official told us that VHA monitors performance by calculating quarterly  VAMC scores on all performance metrics, which are published on the  PDSI clinical management dashboard. VHA also disseminates these  scores to the VISNs in the semiannual feedback reports. In these  feedback reports, VHA highlights any metric—from the current or a past  phase—for which a VAMC within that VISN has regressed. A VHA official  stated that if a VAMC regresses significantly in any area, VHA would work  with that medical center to determine the cause and take action to  reverse the trend as needed.

See appendix III for information on PDSI’s planned focus on reducing the  co-prescribing of benzodiazepines and opioids as well as the initiative’s  collaboration with VHA’s Academic Detailing program, which has  developed its own campaign related to stimulant prescribing.

VHA Has Included Psychotropic Medications in Multiple Efforts to Examine Suicide Risk among Veterans

Since 2012, VHA has included psychotropic medications in multiple  efforts to examine suicide risk among veterans, including two programs  and three research studies. These efforts include:  Recovery Engagement and Coordination for Health – Veterans  Enhanced Treatment (REACH VET) Program. VHA includes  psychotropic medications as part of its effort to examine veterans who  may be at risk of suicide through its REACH VET program. Specifically,  REACH VET uses prior research findings to conduct predictive modeling  on data collected from VHA’s electronic medical records to identify  veterans who are within the top tier (0.1 percent) of predicted suicide risk.  These veterans may also be at increased risk of other adverse outcomes,  such as overdoses, violence, and mental health hospitalization. Of note,  five of the 61 variables used in REACH VET’s predictive model relate to  the prescription of specific psychotropic medications (e.g., alprazolam),  and three relate to the prescription of specific psychotropic classes (e.g.,  antidepressants). Other variables used in the model include  demographic characteristics, past suicide attempts, measures of VHA  care utilization, and certain diagnoses such as substance use disorder,  MDD, and chronic pain.

REACH VET coordinators staffed at VAMCs are responsible for notifying  the appropriate mental health provider or PCP that a veteran has been  identified as being at high risk for suicide, based on a high-risk list of  veterans generated monthly by REACH VET’s predictive model. As  shown in Figure 4, veterans identified as being at high risk for suicide  may then receive targeted outreach from their mental health providers or  PCPs if those providers conclude that outreach is warranted based on  their review of the veterans’ medical records, according to VHA officials.  This outreach may result in changes to the veteran’s treatment as agreed  upon by the provider and veteran. VHA reported that within the first year  of nationwide implementation, February 2017 through February 2018, the  program identified close to 30,000 veterans at high risk for suicide.

Behavioral Health Autopsy Program. VHA also includes psychotropic  medications in its Behavioral Health Autopsy Program. This program  examines information about veteran deaths by suicide that are reported to  VAMC providers and suicide prevention coordinators.

When informed that a veteran has died by suicide, suicide prevention  coordinators are to electronically report, among other things, whether the  veteran had (1) been prescribed psychotropic and other medications, for  the treatment of a mental health condition within the previous year, and  (2) adhered to the medications. Other sources of information collected  through the program may include coroners’ and medical examiners’  reports, death certificates, and information provided by family members  and significant others. Data are reported to and analyzed by VHA’s VISN  2 Center of Excellence for Suicide Prevention. One recommendation in  the program’s 2017 annual report called for more efforts to study issues  related to medication management, such as veterans’ medication  adherence, overmedication, and frequent and abrupt medication  changes. In the past, recommendations from the program have been  used to inform VHA suicide prevention policies, programs, and  educational efforts, according to VHA officials. For example, officials  shared that the program informed the development of a tool kit for  providers to use to help address veterans’ sleep issues after analyses  found that sleep patterns were often altered for veterans prior to their  death by suicide.

Lithium for Suicidal Behaviors in Mood Disorders study. As of March  2019, VHA is in the process of conducting a randomized clinical trial that  examines the effect of a specific psychotropic medication (lithium) on  reducing suicide risk for veterans with MDD or bipolar disorder who either  survived a recent suicide attempt or were hospitalized to prevent one.  VHA plans to enroll 1,600 veterans in the study from 28 VAMCs and  provide them with the appropriate treatment options as determined by  their respective providers, as well as provide some additional care  coordination. Additionally, half of the participants will receive lithium,  and half of the participants will receive a placebo. The study’s  investigators told us that, to their knowledge, this study is the first effort to  test lithium’s efficacy for reducing suicide risk in a randomized clinical trial  setting. Investigators also told us that, because all participants will receive  medications already proven safe and effective for the treatment of their  conditions, it is not considered unethical to withhold lithium, a yet  untested medication for treating suicide risk, from half of participants.  VHA investigators told us they hope to use the results of this clinical trial  to inform future treatment options for patients with MDD or bipolar  disorder and who are at risk of suicide.

Drugs and Suicide Risk study. Between January 2017 and October  2018, VHA officials and collaborators at the University of Chicago and  Columbia University analyzed 513 medications, which included  psychotropic medications, prescribed between 2003 and 2014 for  association with increased or decreased risk of suicidal events in VHA  patients. According to the study’s investigators, they expect to be able to  identify specific psychotropic medications that are found to be associated  with the largest increases and decreases in suicide risk. VHA officials told  us that as of March 2019, the research manuscript was under review for  publication in a peer-reviewed journal.

Using Big Data and Precision Medicine to Assess and Manage  Suicide Risk in U.S. Veterans study. As of March 2019, VHA officials,  in collaboration with the Department of Energy, were in the process of  developing a new model to predict suicidal behavior among veterans by  combining data on genetic and non-genetic risk factors, such as  demographics, medical conditions, and stressful life events; psychotropic  medications are also included as a risk factor, according to VHA  officials. The researchers are expected to combine data from VHA  electronic medical records with data from a VHA Office of Research and  Development program that collects genetic information from veterans to  develop the new algorithm.

VHA officials we interviewed noted some broad challenges not exclusive  to VHA that may affect efforts for any researcher in examining suicide risk  and the use of psychotropic medications:

Multiple risk factors. All VHA officials that we spoke with discussed  the need for efforts examining psychotropic medications and suicide  risk to account for other suicide risk factors beyond the use of these  types of medication. Such factors may include having a substance  use disorder or other mental health diagnoses; homelessness; chronic  (non-mental health) medical conditions; age; and psychosocial  factors, such as recent loss of a significant other or a history of abuse  or violence.

Methodological considerations. Most VHA officials that we spoke  with mentioned some methodological considerations that must be  considered when designing a research study to examine this  relationship. For example, an official told us that measuring veterans’  medication adherence is important to track, but is difficult to do as  VHA generally only has data on whether medications were dispensed  to veterans, not whether medications were actually taken.

Ethics. Some VHA officials that we spoke with noted that certain  ethical considerations may limit the methodological options available  to researchers, such as randomized clinical trials. For example, it  would be unethical to withhold medications that have been proven as  safe and effective from veterans who may clinically benefit from  receiving such treatments, such as from veterans in a control group.

In the face of these challenges, VHA officials also noted some  advantages VHA researchers, in particular, may experience in examining  the use of psychotropic medications and suicide risk: a large patient population with more than 2 million veterans who  have at least one mental health condition, and a corresponding  electronic medical records database, providing sufficient data and  sample sizes needed to test hypotheses;  internal funding streams dedicated to research activities examining  issues related to suicide prevention, such as funds available through  three of VA’s Office of Research and Development’s four central  research services; and  research centers with researchers who have specific expertise about  issues related to suicide prevention and the treatment of serious  mental health conditions.

Veterans diagnosed with mental health conditions rely on providers in  VAMCs across the country to make treatment decisions that are safe and  effective, including whether to treat highly prevalent and serious  conditions such as MDD and PTSD with psychotropic medications, non- pharmacologic therapy, or a combination of both. In recent years, VHA  has taken steps aimed at improving the safety and effectiveness of  prescribing decisions for certain psychotropic medications and noted  important improvements resulting from these efforts. However, VHA’s  oversight related to treatment planning needs improvement. VHA has yet  to disseminate guidance that clearly reflects its expectation that mental  health providers in specialty care document mental health treatment plans  in a readily identifiable manner in veterans’ medical records. Additionally,  VHA does not monitor whether mental health providers are considering  evidence-based treatment options in treatment plans, as VHA requires in  its mental health services handbook. As a result, VHA cannot ensure that  providers are considering and documenting all appropriate treatment  options, adequately evaluating patient care, and making treatment  modifications as necessary, among other issues. Furthermore, the lack of  monitoring may impede VHA’s ability to identify important factors that  contribute to providers’ treatment decisions, which could in turn allow  VHA to identify more systemic barriers to safe and effective treatment,  such as needed training.

In addition, being able to readily identify how veterans are being treated  for mental health conditions may allow VHA to enhance its research  efforts related to suicide risk. VHA has noted several advantages it has in  conducting research involving the role of psychotropic medications in  suicide risk among veterans, including that VHA researchers have access  to a large patient population with at least one mental health condition.  Monitoring veterans’ use of psychotropic medications and non- pharmacologic therapies and related outcomes may further enhance this  capacity for research on suicide risk.

We are making the following two recommendations to VA:  The Veterans Health Administration should disseminate guidance for  VISNs and VAMCs that more clearly reflects its expectation that mental  health providers in specialty care should record mental health treatment  plans within veterans’ medical records in an easily identifiable way.  (Recommendation 1)

The Veterans Health Administration should develop and implement an  approach for monitoring treatment plans for veterans with mental health  conditions to ensure that such plans include documentation that different  evidence-based treatment options were considered. (Recommendation 2)

We provided a draft of this report to VA for review and comment. In its  written comments, which are reproduced in Appendix IV, VA concurred  with our recommendations. VA agreed that the recommendations would  promote adherence to mental health treatment planning requirements. VA  stated that it is developing guidance to help ensure that mental health  providers in specialty care record mental health treatment plans in  separate, easily identifiable documents within veterans’ medical records.  VA also stated that it will develop and implement a process for monitoring  whether such plans include documentation that providers considered  different evidence-based treatment options. We will monitor VA’s efforts  to address our recommendations.

As agreed with your office, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies to the appropriate  congressional committee and the Secretary of Veterans Affairs. In  addition, the report will be available at no charge on the GAO website at  http://www.gao.gov.

If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or at DraperD@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. GAO staff who made key contributions to this  report are listed in appendix V.

Appendix I: Mental Health Treatment Practices for Veterans in a Nongeneralizable Sample of Selected Medical Centers

We reviewed a nongeneralizable, randomly selected sample of 75  veterans’ medical records from five Department of Veterans Affairs (VA)  medical centers (VAMC)—25 for each of the three most prevalent  conditions diagnosed among veterans—who had at least one primary  care visit in fiscal year 2017 and were prescribed a new psychotropic  medication. About half (37) of the 75 medical records we reviewed  indicated the veteran was prescribed a new psychotropic medication prior  to or without being referred to a mental health provider in specialty care.  See table 4.

We reviewed a separate, nongeneralizable, randomly selected sample of  an additional 75 veterans’ medical records from the five VAMCs—25 for  each of the three most prevalent conditions diagnosed among veterans— who were newly diagnosed within that year. Over half (44) of the 75  medical records we reviewed indicated whether the veteran was offered  non-pharmacologic therapy in lieu of or in addition to being prescribed a  psychotropic medication. See table 5.

Appendix II: Information on the Treatment of Veterans with Certain Mental Health Conditions, Nationally, in Fiscal Year 2018

We analyzed national data obtained from VHA on the types of treatments  received by veterans with a diagnosis of a single mental health condition  who had encounters with VHA providers for that diagnosis in fiscal year  2018, including the three most prevalent mental health conditions  diagnosed among veterans. See Figure 5 for the percentages of  veterans with these three conditions or another mental health condition  who received (1) non-pharmacologic therapy (psychotherapy), (2) at least  one medication from a psychotropic medication class, (3) a combination  of the two, or (4) neither psychotropic medication nor non-pharmacologic  therapy in fiscal year 2018.

We also analyzed national encounter data obtained from VHA for  veterans with one of the three most prevalent mental health conditions  and who received psychotropic medications in a VA medical center  (VAMC) in fiscal year 2018. We found that for all three conditions, the  largest percentage of veterans who received at least one psychotropic  medication from one class were seen in the primary care setting only. The  percentages of veterans with medications from two or three classes— typically veterans who had more complex mental health conditions,  according to a VHA official—were larger for veterans seen by specialty  care providers, compared to the percentages of veterans with  medications from multiple classes seen in primary care only. See Figure  6.

Appendix III: PDSI’s Planned Focus on Medication Tapering and Collaboration with VHA’s Academic Detailing Program

The Veterans Health Administration (VHA) has taken steps to improve the  safe and effective prescribing of certain psychotropic medications used to  treat veterans with mental health conditions through the Psychotropic  Drug Safety Initiative (PDSI). PDSI has consisted of three phases since  2013, when the initiative began. Each phase has focused on making  improvements related to the prescribing of different classes or types of  psychotropic medications, or treating different age groups or mental  health conditions and substance use disorders. PDSI is currently in phase  3, and VHA is in the process of planning for phase 4.

According to a VHA official, PDSI phase 4 (expected to begin in July  2019) will, in part, increase the role of mental health providers in the  monitoring and management of the co-prescribing of benzodiazepines (a  type of antianxiety medication) and opioids. This includes tapering the  use of these medications among this high-risk veteran population to a  reduced dose or discontinuation entirely when the harms associated with  their concurrent use outweigh the benefits. The same official told us that,  to date, VHA has primarily focused on monitoring the concurrent use of  these medications—which the Department of Veterans Affairs’ and the  Department of Defense’s clinical practice guideline (CPG) for opioid  therapy strongly recommends against—through the Opioid Safety  Initiative and in the primary care setting (see text box).

Veterans Health Administration’s (VHA) Efforts to Taper Veterans Co-Prescribed  Benzodiazepines and Opioids  Efforts focused on the establishment of safe and effective tapering programs in  the primary care setting:  VHA launched the Opioid Safety Initiative in 2013 to ensure that veterans are  prescribed and use opioid pain medications in a safe and effective manner. This  initiative seeks to establish safe and effective tapering programs for veterans who  are co-prescribed opioids and benzodiazepines, among other goals.  A VHA official told us that the initiative primarily focuses on monitoring and  managing the concurrent use of these medications in the primary care setting.

Efforts conducted on an individualized, gradual basis:  The Department of Veterans Affairs’ and Department of Defense’s clinical practice  guideline (CPG) for opioid therapy strongly recommends that tapering of opioids be  done on an individualized basis, weighing the benefits and risks to each veteran as  well as the veteran’s characteristics and needs.  The CPG also notes that the sudden stopping of benzodiazepines should be  avoided, since doing so can lead to seizures or death.

Department of Veterans Affairs and Department of Defense, Clinical Practice Guideline for Opioid  Therapy.

To help achieve PDSI’s goal of improving the prescribing of certain  psychotropic medications, VHA officials leading PDSI collaborate with  VHA’s Academic Detailing program. Academic detailers, who are  Veterans Integrated Service Networks (VISN) or Department of Veterans  Affairs (VA) medical center (VAMC) clinical pharmacy specialists,  disseminate resources and provide one-on-one educational outreach to  providers to help them improve their psychotropic medication prescribing  practices. Pharmacy staff, including staff involved in academic detailing,  from four VISNs told us that they provide education related to PDSI. The  Academic Detailing program has also implemented a campaign to  improve the appropriate prescribing and monitoring of stimulants (see text  box).

Veterans Health Administration’s (VHA) Academic Detailing Program Prescription  Stimulants Campaign  According to a VHA official, in February 2018, the Academic Detailing program  implemented a campaign to improve the treatment of patients receiving prescription  stimulant therapy for adult attention-deficit / hyperactivity disorder.

A VHA official told us that Veterans Integrated Service Networks (VISNs) or  Department of Veterans Affairs (VA) medical centers (VAMCs) may choose, but  are not required, to participate in this campaign.  The stimulant campaign dashboard includes VAMC scores on 13 quality indicators  related to (1) prescribing stimulants for off-label use, (2) assessing co-morbidities,  (3) monitoring patients, and (4) managing medication. For example

One quality indicator measures the percentage of veterans co-prescribed a  stimulant and a benzodiazepine, and  Another quality indicator measures the percentage of veterans co-prescribed a  stimulant and an opioid.

Academic detailers (VISN or VAMC clinical pharmacy specialists) may use the  dashboard to identify providers who may benefit from changes to their stimulant  prescribing practices.  A VHA official reported that between February 2018 and the end of fiscal year  2018, academic detailers made 37 staff interactions with providers related to the  national academic detailing program’s stimulant campaign.

As of October 2018 (the most recent data available), 37,223 veterans with at least one  diagnosed mental health condition had an active prescription for at least one stimulant,  according to a VHA official. Among these veterans, 2,360 had a co-occurring cardiac  condition.Sudden death, stroke, or other cardiac events have been reported with stimulants. The U.S. Food  and Drug Administration has stated that stimulants should generally not be used in patients with  serious heart problems or for whom an increase in blood pressure or heart rate would be  problematic. See U.S. Food and Drug Administration, FDA Drug Safety Review Communication:  Safety Review Update of Medications Used to Treat Attention-Deficit / Hyperactivity Disorder  (ADHD) in Adults, accessed March 1, 2019,  https://www.fda.gov/Drugs/DrugSafety/ucm279858.htm.

Appendix IV: Comments from the Department of Veterans Affairs

Appendix V: GAO Contact and Staff Acknowledgments

In addition to the contact named above, Hernán Bozzolo (Assistant  Director), Kaitlin Asaly (Analyst-in-Charge), Jennie F. Apter, Karen Belli,  Topher Hoffmann, and Rebecca Rust Williamson made key contributions  to this report. Also contributing were Rich Lipinski, Diona Martyn, Vikki  Porter, and Jennifer Whitworth.

VA's mental health care providers have options, such as medication and therapy, to treat veterans with mental health conditions. VA has taken steps to improve mental health treatment, such as prescribing medications with dangerous side effects less frequently.

However, VA doesn't monitor whether providers are documenting that they have considered different options before deciding on a treatment plan, as guidance suggests.

Providers are also supposed to document treatment plans in an easily identifiable way in veterans' medical records, but VA hasn't given them guidance on how to do this.

We recommended that VA address these issues.