Arizona veteran suicides a tragic cost of broken VA system

• During the 2013 budget year%2C 226 Arizona veterans took their own lives%2C according to state records.
• According to VA calculations%2C 22 U.S. veterans kill themselves each day.
• The suicide rate among male vets under 30 is up 44 percent over three years.

David Klein leaned forward, scrunching his face in deliberation.

A journalist had just asked whether, as a ­Department of Veterans Affairs suicide- ­prevention coordinator for seven years, he was able to meet the needs of Arizona veterans.

Charts and spreadsheets were piled in front of him on a table at the Phoenix VA's mental-health clinic, filled with data on suicides.

Klein paused before answering in a hushed voice: "Ummm, no. I wish I would have had a lot more people."

During the 2013 budget year, 226 Arizona veterans took their own lives, according to state records. More than 2,000 vets from metro Phoenix dialed the VA's central crisis line; 61 were "rescued" after they threatened to kill themselves. It was the second-highest number nationwide.

Amid the national outcry over VA health care — a controversy that first exploded in Phoenix — failures in the mental-health treatment system have been heavily criticized. According to VA calculations, 22 U.S. veterans kill themselves each day, using guns, blades, drugs and other means.

Veterans take their own lives more frequently than the general population, and more violently. News21, an investigative program for journalism students, calculated last year that ex-military personnel commit suicide at a rate of 30 per 100,000 population, compared with 14 per 100,000 among civilians.

The rate among male veterans under 30 reportedly is up 44 percent over three years, according to the VA. The rate among women vets increased 11 percent. While department officials say overall suicide rates are not on the rise, VA data is chronically suspect.

A recent poll by the Kaiser Family Foundation and the Washington Post found more than half of post-9/11 veterans know another who committed suicide or made an attempt.

A National Academy of Sciences report in 2013 ripped the VA for delayed mental-health care to military personnel returning from Iraq and Afghanistan, 44 percent of whom are diagnosed with psychiatric conditions.

Meanwhile, investigations by the VA Office of Inspector General and Office of Special Counsel have exposed widespread mismanagement and treatment breakdowns.

• In Georgia last year, the IG said 16 veterans sidetracked in the appointment system had attempted suicide while awaiting mental-health care.

• In St. Louis, Chief of Psychiatry Dr. Jose Mathews discovered doctors on his staff were seeing just six veterans a day — spending only 3½hours in patient contact per shift. Mathews testified in a House hearing that veterans became so frustrated with VA mental-health care they quit showing upafter one or two visits. When he tried to enact reforms, he was investigated, bullied and removed from his job.

• At the VA hospital in Brockton, Mass., an Office of Special Counsel report says one psychiatric patient went eight years without an evaluation. Another went seven years without a note in his chart.

The deficiencies aren't new: In 2005, the VA told Congress it was building an electronic tracking system to monitor suicides. Nine years later, systemic shortcomings remain difficult to identify because VA officials are unable or unwilling to provide significant data to lawmakers, veterans' groups or the media.

Klein divulged some statistics during an interviewwith The Arizona Republic in late July, but a VA spokeswoman said she could not provide copies of spreadsheets and graphics. The VA refuses to release a report Klein prepared last year on Phoenix's suicide problem, despite a request by the newspaperfour months ago under the Freedom of Information Act.

Rep. Kyrsten Sinema, D-Ariz., who's taken on VA mental-health care as a special project, said she has received no statistical information on suicides or wait times at Phoenix VA despite repeated meetings with hospital administrators.

"I have only anecdotal data," Sinema acknowledged. "It's really hard to get answers, to get the truth. ... I've never seen an agency so resistant, and it hasn't gotten better."

Even the limited information divulged by VA officials seems questionable. For example, they reported 12 veteran suicides in the Phoenix area in 2012, and 49 last year. Then they explained that the seeming increase of more than 400 percent was caused by a change in data collection last year. By checking deaths from the Maricopa County Medical Examiner's Office in 2013, they learned of another 31 Phoenix veterans who took their own lives.

Even the suicide total, 49, appears to be inaccurate. Arizona vital statistics show 226 people with military service records killed themselves last year. Maricopa County contains more than half the state's population. Yet, by the VA's calculations, it would account for barely one-fifth of Arizona's veteran suicides.

Such statistical glitches appear to be widespread in the VA.

A 2012 OIG review found that, on average, patients seeking first-time mental-health care from the Veterans Health Administration did not get comprehensive evaluations for more than seven weeks. Yet the VA claimed 95 percent success in meeting a goal of providing appointments within 14 days of requests.

The OIG's No. 1 finding: "Performance measures used to report patients' access to mental-health care do not depict the true picture of patients' waiting time to see a mental-health provider."

Haunted for life

Brian Mancini served 13 years as a U.S. Army medic, and was on a second combat tour when a roadside bomb blew up his military career in 2007.

Mancini says he spent more than 3½ years at the Walter Reed National Military Medical Center "getting my face rebuilt" and undergoing therapy. He returned to Arizona with two Purple Hearts, post-traumatic stress disorder, traumatic brain injury, a missing eye, chronic pain and a titanium plate in his head.

As Mancini sees it now, America is afflicted by a delayed casualty syndrome. During the Vietnam War, the ratio of combat fatalities to non-fatal wounds was 1 to 2.6. In Iraq and Afghanistan, due to improved armaments and medical technology, just 1 of 17 casualties is fatal. But many survivors are haunted for life by PTSD and concussive brain injuries from improvised explosive devices.

In Phoenix, Mancini says he turned to the VA Medical Center and immediately learned that his cocktail of medications, which took years to perfect at the Army hospital, was not on the official formulary, so he'd have to start over. He found himself waiting interminably for appointments, unable to get approval of outside acupuncture and chiropractor treatments for agonizing headaches and other pain.

"There was a really dark period of my life when I literally just lay on the floor in my house crying," Mancini recalls. "I just was really frustrated with the lack of care. I felt betrayed.

"All they wanted to do was throw a lot of drugs at me, and those were having an adverse effect. They had me on 12 medications at one point. ... I finally said, 'You know what? I'm done.'

Mancini says he decided to use his medical background to develop an alternative treatment regimen with therapies available in the community — from brain training to yoga to fly-fishing. He wrote up a handbook and founded an Arizona non-profit known as Honor House, then arranged a presentation to Phoenix VA Health Care System Director Sharon Helman two years ago.

The session did not go well, he recalls: "She was more appeasing me than anything."

Mancini turned next to Terros Inc., a community health-care organization that focuses on inspirational life changes. Terros adopted the treatment program and launched a pilot effort, then joined in a second attempt to get Phoenix VA involved.

This time, Mancini says, Helman — who now faces termination in connection with alleged mismanagement at the Phoenix VA — reacted defensively.

"I emphasized the need to go out of network to get veterans the service they so desperately needed regarding PTSD," he wrote in an e-mail. "I specifically commented on the ridiculous wait times and presented a solution — with very little interest."

Anguished note

That same year, 2012, a VA employee wrote to Susan Bowers, director of the VA Southwest Health Care Network, complaining that he was forced to wait 10 months for a mental-health appointment.

In the letter obtained by The Arizona Republic via a records request, he described a system so broken that even a VA staffer couldn't penetrate the bureaucracy.

"Some of our veterans with PTSD, this kind of treatment is what sets them off," he wrote, "and it could escalate into a behavioral emergency very quickly, or they just leave and NEVER come back. Worst of all, what about the suicidal veteran who is reaching out for the first time for help? These kinds of events are what can make them feel like nobody cares, and they go home and blow their head off."

Helman advised Bowers she would look into the situation.

Months later, in June 2013, Iraq War veteran Daniel Somers made that letter seem prescient: He took his own life and left behind an anguished suicide note that was posted online.

"During my first deployment, I was made to participate in things, the enormity of which is hard to describe," Somers wrote."War crimes, crimes against humanity. To force me to do these things ... is more than any government has the right to demand. Then, the same government has turned around and abandoned me."

"Is it any wonder that the latest figures show 22 veterans killing themselves each day?"

Helman sent an e-mail to Bowers, warning her boss that the Somers letter had created a "lightning bolt for us in regards to our (patient) scheduling."

"We were already working on improving," she added. "... We are expediting the urgency in making these improvements happen."

There is no evidence from VA records supplied to The Republic that significant changes were initiated at that time. Helman has declined interview requests since she was suspended in May.

Pleading for help

Jean and Howard Somers said their son, Daniel, went to the Phoenix VA Emergency Room seeking hospital admission. When told there were no beds available, he lay on the floor, weeping and pleading for help.

"There was no effort made to see if he could be admitted to another facility," Howard Somers testified. "But, he was told, 'You can stay here and when you feel better you can drive yourself home.' "

The Somerses said they met with Helman after their son's death and were informed that wait times for mental-health care had dramatically improved.

They've since learned that VA patient-access records were a fiction. They don't even know if Daniel's final act was counted in the Phoenix VA's suicide tally.

"It's like with any statistics out of the VA," Howard Somers said. "What data are they using? Where did they get the numbers?

"All we can think is, we were being lied to like everybody else."

The couple testified before Congress last month and created a reform plan for VA suicide prevention. They also have done the math: If 22 veterans kill themselves daily, and the number has been constant for years, more than 100,000 men and women who served America have taken their own lives since 2001.

That's roughly 15 times the number of U.S. military personnel who died in Iraq and Afghanistan during the same period.

Placed at higher risk

Not long after Daniel Somers died, Phoenix VA whistle-blowers began filing complaints with the Office of Inspector General and Congress about delayed health care, falsified wait times and patient deaths.

Dr. Katherine Mitchell, a 16-year employee, had risen through the system from nurse to physician to ER supervisor. She is now medical director over a VA transition program for Gulf War veterans. In that capacity, Mitchell says she learned of systemic problems that "were placing our veterans at higher risk of successful suicide completion."

"Despite phenomenal attempts by the Suicide Prevention Team to work within the confines of grossly inadequate resources, the rates of suicide at the Phoenix VA substantially increased over a very short time," she wrote in a complaint. "Senior administration's response or, rather, lack of appropriate response, heightened my concerns."

Mitchell described staffing shortages and inadequate or incompetent triage by mental-health nurses. She said walk-in patients in crisis routinely were sent to the VA eligibility office to complete enrollment papers before getting treatment. "The diversion of patients for acute physical or psychological issues is not only against national community standards, but also defies common sense," Mitchell wrote.

In one case, she alleged, a veteran told mental-health staffers he'd just been randomly firing a weapon. Yet he was sent away with literature on substance-abuse counseling and an admonition not to carry a gun. Mitchell said police arrested that veteran a short time later for discharging a firearm.

Another walk-in patient, suffering from PTSD and in need of medications, waited more than 2½ hours for an appointment, only to be sent home at closing time with instructions to return in the morning, Mitchell reported.

Mitchell pointed out that patient loads were increasing amid an exodus of psychiatrists and social workers who left in search of better work conditions and pay. The crunch was compounded by the closure in 2011 of the Phoenix VA's Controlled Substance Clinic, which provided medication to 950 veterans suffering from chronic pain and mental-health issues, she alleged.

VA records obtained via the Freedom of Information Act indicate the operation was shut down because drugs were distributed in violation of federal law. In e-mails to administrators at the time, employees warned that angry patients needing prescriptions would swamp primary-care and mental-health doctors.

"This could overwhelm the current system and put veterans at risk of withdrawal, self-medication, overdoses and death," wrote one physician.

Other staffers predicted that veterans might become disruptive, even a safety threat. "Ceasing to provide this service ABRUPTLY IS POTENTIALLY DANGEROUS, medically and psychologically," wrote an employee. "In addition, can you say Disruptive Patient maybe even 950 times?"

The impact of the clinic closure is not evaluated in documents provided by the VA. But, in a 2013 complaint to the OIG, Dr. Mitchell noted, "At least four of the suicides I have reviewed are related to poorly controlled pain."

Angie Seidel, a mental-health nurse who recently retired after 36 years with the Phoenix VA, said patient care was hampered by staff shortages and a dysfunctional administration.

"With the low number of psychiatrists, it was demanding, but people would hang tough," said Seidel. "We had those who went out and killed themselves because they couldn't wait for care, which is tragic. But we had a pretty good rhythm in the clinic, a good dance."

Stress on the system continued into early 2014. Mitchell alleged that vacant positions on the Suicide Prevention Team were not filled, and said Klein transferred to another job in February "after many years of struggling to get adequate resources."

Sen. John McCain, R-Ariz., submitted portions of Mitchell's complaint to VA administrators requesting an OIG inquiry that apparently did not occur. Instead, Mitchell was suspended and given a letter of rebuke based in part on allegations she improperly viewed suicide charts.

Meanwhile, the VA's congressional liaison, Michael Huff, told McCain that all veterans' suicides in Phoenix from 2011 to 2014 had been reviewed.

In April, Mitchell wrote to Helman, warning again about staffing shortages. "There is a high likelihood veteran suicide deaths will continue to increase because SPT is too diluted to do effective outreach and care to all of our high-risk veterans. ... I have noted veterans discharged from the hospital (psychiatric unit) after severe depression/suicide attempts who have not been assigned a regular psychiatrist even after months."

By May, according to internal VA e-mails, about 150 Phoenix veterans were still backlogged — unable to get timely psychiatric appointments. Mitchell reported that chronically suicidal patients faced waits of up to 60 days for specialized therapy, while those with PTSD had appointment delays exceeding 30 days.

Changes implemented

Klein and David Jacobson, chief of social-work service in the Phoenix VA Health Care System, said Mitchell's allegations were true at the time. However, they added, in the past few months Phoenix officials have pursued an all-out effort to fix mental-health programs. Among the changes:

• The VA has hired more than a dozen additional psychiatrists and is adding social workers, psychologists and other mental-health specialists as fast as they can be signed up.

• The Suicide Prevention Program now has three staffers, and is recruiting a coordinator and another case manager.

• The hospital emergency room, which previously had no mental-health providers, now provides 24-hour staffing by social workers, plus an on-call psychiatrist.

• A new access system assigns a treatment coordinator to each mental-health patient with three or more visits.

• Planning is underway for an additional mental-health building.

While the system remains understaffed, Jacobson said, patients who once faced long waits are now referred to outside providers for timely care. And the backlog is nearly gone.

"Our accessibility in mental health just has improved phenomenally since this whole crisis began," Jacobson said.

Battling demons

Robert Yett was a decorated corpsman who served 17 years in the Navy.

He survived two combat tours in Iraq and multiple missions with special operations units. But he could not navigate the health-care system, or defeat the demons of PTSD and depression.

"I 100 percent put the weight of his death, the responsibility for his death, on the VA," says Victoria Yett, his widow. "They turned him away. ... And now I'm raising four boys without a father."

Like so many others, Robert spiraled into despair and bounced between the VA and other mental-health programs. Symptoms swirled together: drinking, an auto accident, domestic violence, hallucinations, unemployment.

Family members created a timeline: After a breakdown in early November 2010, Yett was involuntarily committed to a mental hospital under Magellan Health Services. He was scheduled for transfer to Phoenix VA medical center's psychiatric ward. Dawn Lake, a retired Army lieutenant colonel and family friend, arranged for the admission. But, when they arrived at the hospital just after 4 p.m., the mental-health clinic was closed. Yett was sent to the emergency room, which had no psychiatric staffers.

At the time, VA medical records show, Yett was under court order to receive treatment, and was listed as a "danger to others."

Victoria Yett says her husband was a warrior who would not be open about weakness or despair. Though he asked to be admitted to the psychiatric unit as an inpatient, records show, he also claimed he felt fine and denied having suicidal thoughts. He was turned away.

He decided to stay in the ER until morning when the mental-health clinic would reopen and he could see a counselor. Around 1 a.m., Victoria says, VA police kicked Robert out. He paid $100 for a cab ride home to the San Tan Valley area.

In the final days, Victoria says, her husband gave up on the system. Hebegan calling friends to report that he'd had an epiphany: He finally understood the meaning of love. He'd hurt his wife, his children, others, and he wanted to apologize. He worried about being homeless, about ending up under a bridge.

Robert Allan Yett Jr. died on or about Nov. 20, 2010, at age 40.

The official finding was an overdose, but family members say he was a casualty of war and a victim of the nation's dysfunctional health care for veterans.

"The VA was supposed to take care of Robert," his widow says. "They were supposed to stand up for him and provide the specialized care he needed after combat. And they failed him miserably."

Overwhelmed program

There is no way to determine how many military veterans took their own lives because of treatment failures, or how many might have been saved if VA care had been better.

Klein, who became manager of the Phoenix VA's Mental Health Intensive Case Management program early this year, said his Suicide Prevention Team was so overwhelmed in 2012 and 2013 that it had time only for crisis patients, and was unable to focus on those at moderate risk of taking their own lives.

Klein said 1 of 10 vets who commit suicide is enrolled in a VA mental-health program. He said there is no statistical link with combat service, but clear evidence that divorce, financial problems, loss of employment and other psychosocial factors are key.

Those issues may be magnified, he said, if a veteran is fighting the bureaucracy for VA benefits, psychiatric appointments or the right medications. Hassles build up and can become triggers, especially among patients suffering from PTSD and other conditions.

Klein described troubled vets using the metaphor of an overflowing glass: "They come here to feel safe. We try to take a little bit of water out of their glass. Sometimes, it's just talking to them."

For those in crisis, he added, there is usually no problem getting immediate help. Mental-health workers understand the urgency. "When they get a call from the suicide-prevention coordinator saying we have a patient who needs care, we get an appointment pretty soon."

But he also noted that many veterans — stuck in macho mode, turned off by bureaucracy, fearful of a mental-health stigma — won't turn to the VA for help, or drop out of the system. They are the most vulnerable, he said: "Untreated depression is the Number 1 cause, 68 times higher than the general population."

'My mind was frayed'

A veteran's suicide cannot be explained with a postmortem, like death by cancer.

There may be detectable brain injuries and behavioral symptoms, but the psychological causation inevitably leaves families and caregivers wondering: Why? What was the last straw? What could we have done?

Former U.S. Marine Corps Sgt. Lance Davison fought in Afghanistan and Iraq, was wounded more than once, lost friends in combat, earned a Bronze Star and a Navy Commendation Medal, suffered PTSD and traumatic brain injury.

After leaving the military in 2004, he joined the Flagstaff Police Department. He seemed to thrive, earning two commendations for valor.But hidden wounds took a toll. He turned to booze, which led to a bar fight and other scrapes with the law. He lost his job, his wife and his life.

In congressional testimony, John Davison said he's reviewed his son's struggle to cope, and to get help from VA hospitals in Phoenix and Tucson.

"I have connected some of the dots, but there are many unanswered questions. The VA toolbox for assisting PTSD/TBI victims seems very limited. There is an inappropriate and troubling over-reliance on the administering of drugs for treatment."

During an outburst three years ago, Lance Davison set fire to his porch and then crashed his truck. In a 2012 letter to Maricopa County Superior Court seeking to have the criminal conviction set aside, Davison said his behavior was "a result of psychological stress from years of service to my country."

"I have lived and experienced life well outside the normal human condition," he wrote. "I firmly believe there exists a mental threshold that each man owns. I may have spanned mine."

Davison's letter said Phoenix VA had switched his drug regimen to a mix of sleeping pills, antidepressants and psychotropic medications. "I had 32 different cocktails, 32 different combinations of drugs," he wrote. "The circumstance I found myself in was that I never had a constant care provider, people would leave and move on to other jobs so there was no safety net.

"My mind was frayed. In no other state would I ever burn my porch and driven (sic) my truck into a pool. I was hallucinating. I was simply reliving my time in Iraq."

Davison accepted responsibility for abusing alcohol, but added: "I was attempting to alleviate my symptoms and the kaleidoscopic mental circus. … I went above the court's recommendation and spent 50 days in an in-patient treatment PTSD and alcohol treatment program. However, I find … just like in combat, there are no right answers."

His civil rights were restored in 2012, but he never found the right answers.

On Feb. 9, Davison ended the search.

"These kids are coming home and they've got all of these problems," his father said. "I don't think people really know the crisis we're in. If we were losing 22 high-school students a day, or elementary-school students …

"Lance was a tragedy. It hurt a lot of people. I want some good to come out of it."

Suicide hotline info

Veterans, family members and friends facing a mental-health emergency or dealing with suicidal thoughts may contact the 24-hour VA Crisis Line for immediate, confidential help. Calls are routed to the nearest crisis center in a national network. This phone number, also known as the National Suicide Prevention Lifeline, serves the non-veteran population as well.

VA Crisis Line: 1-800-273-8255

Texts: 838255

Online chat:veteranscrisisline.net (Click on "Confidential Veterans Chat" box at top of Web page.) These services provide counseling and referral assistance for veterans in crisis over suicidal thoughts, homelessness, relationship issues, chronic pain and other issues.

-Additional details on VA crisis services may be found at: veteranscrisisline.net.

-More information on the National Suicide Prevention Lifeline is at: www.suicidepreventionlifeline.org/.

-A list of VA suicide-prevention coordinators, centers and other veterans' services in Arizona is at: veteranscrisisline.net/GetHelp/ ResourceLocator.aspx.

ON THE BEAT

Dennis Wagner has been a beat reporter, columnist and investigative journalist at The Arizona Republic for 31 years. He focuses on watchdog stories involving public money, corruption and misconduct. His April story about a Phoenix VA whistle-blower's allegations ignited the national VA furor.

How to reach him

dennis.wagner@arizonarepublic.com

Phone: 602-444-8874

Twitter: @azrover226