Clinicians at Department of Veterans Affairs facilities have not consistently asked patients who have acknowledged thoughts of suicide about their access to firearms or ways to better store the weapons safely despite department policy requiring those discussions, a VA watchdog found in a report released Thursday.
As part of a broad review of whether the Veterans Health Administration is following policies covering firearm-related suicides, the VA's inspector general examined the health records of 65 patients who died by suicide involving firearms.
Fifteen needed to have a comprehensive suicide risk evaluation prior to their deaths based on department protocols, but three appear to have never been given the evaluation, according to their files. Six of the evaluations for those who did undergo the review did not include any information about the patient's firearm access. Of the remaining six evaluations, all of the patients had documented access to firearms, but three of those cases did not include discussion of safe storage with the patient.
"Given the prevalence of firearm-related suicidal behavior among veterans and the effectiveness of diminished access to firearms in the reduction of suicide, suicide risk assessment and safety planning should include both firearms access and discussion of safe storage," the IG report said. "Failure to adequately assess firearms access and discuss safe storage of firearms may contribute to a failure to promote distance between the patient and firearms as a means of suicide."
In a response included in the report, the VA called safe firearm storage a "critical priority" in its suicide prevention efforts and said it would implement the IG's recommendations by September 2023.
Since 2018, the Veterans Health Administration has used a three-stage suicide risk assessment process that includes a primary screening, secondary screening and a comprehensive suicide risk evaluation. The comprehensive evaluation is supposed to include an assessment of suicidal ideation, behavior and attempts; clinical impressions of acute and chronic suicide risk; and development of a risk mitigation plan.
The comprehensive evaluation may also prompt creation of a safety plan, or a written list of coping mechanisms and available support in a crisis. Clinicians are also supposed to develop a safety plan with patients who recently attempted suicide or expressed suicidal thoughts.
Also in 2018, the VHA issued a template for safety planning that includes documentation of firearms access and instructed clinicians to "[a]lways ask about access to firearms," document the reason if firearm safety was not discussed, and go over "options for improving safe storage" with patients who report access to firearms, according to the IG report.
Of the fatalities the IG looked at, 44 did not require safety plans because they had no previous mental health engagement with the VA or screened negative on a risk assessment. But of 21 patients who should have had a safety plan, four didn't, according to the report.
"On average, the four patients with deficient safety planning died by suicide 48 days after the OIG would have expected VHA to have completed a safety plan with the patient," the report said.
Seventeen patients who died did have a documented safety plan, but four of those plans didn't include information about access to firearms, and one of the 13 that did include information about firearm access did not address safe storage, the report said.
The IG also reviewed 415 patients with nonfatal firearm-related suicide behavior; of those, just 183 came after the full implementation of the 2018 suicide risk implementation strategy.
Of the cases after the implementation of the strategy, 153 completed comprehensive evaluations, 142 of which included an assessment of access to firearms. Thirty-seven of those with access to firearms did not include a discussion about safe storage, according to the report.
In a survey of 183 VA medical center and clinic leaders conducted by the IG, 63% said their staff believes that completing the suicide risk identification strategy "takes too much time."
The IG also surveyed 174 suicide prevention staffers about what influences their decision to discuss firearms access and storage with patients, and 56% said they "assume every patient has access to firearms." Another IG survey of 3,094 clinicians found 45% giving the same answer.
The IG made seven recommendations, including that the VA's under secretary of health "ensures" clinicians complete comprehensive suicide risk evaluations and safety plans and evaluates the staff's perceived barriers to completing the suicide risk identification strategy.
In his response included in the report, VA Under Secretary for Health Shereef Elnahal said the department would update the template for the comprehensive evaluation to explicitly mandate documentation of firearm access and safe storage discussion, find a way to monitor clinician compliance with having those discussions during safety planning, and develop strategies to address the perceived barriers to implementing the suicide risk identification plan.
"Most suicidal crises are brief, and the time from decision to action can be less than one hour," Elnahal wrote in his response. "We can save lives if it takes longer for a person to access the means to harm themselves after the moment they have the impulse to act."
Veterans and service members experiencing a mental health emergency can contact the Veteran Crisis Line at 988, Press 1. They also can text 838255 or chat online at VeteransCrisisLine.net.
-- Rebecca Kheel can be reached at firstname.lastname@example.org. Follow her on Twitter @reporterkheel.