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DOD Needs to Fully Assess Its Non-Clinical Suicide Prevention Efforts and Address Any Impediments To

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DOD Needs to Fully Assess Its Non-Clinical Suicide Prevention Efforts and Address Any Impediments To United States Government Accountability Office Report to Congressional Committees April 2021 DEFENSE HEALTH CARE DOD Needs to Fully Assess Its Non- clinical Suicide Prevention Efforts and Address Any Impediments to Effectiveness GAO-21-300 April 2021 DEFENSE HEALTH CARE DOD Needs to Fully Assess Its Non-clinical Suicide Prevention Efforts and Address Any Impediments to Highlights of GAO-21-300, a report to Effectiveness congressional committees Why GAO Did This Study What GAO Found Suicide is a public health problem The Department of Defense (DOD) has a variety of suicide prevention efforts that facing all populations, including the are implemented by the military services (Army, Navy, Air Force, and Marine military. From 2014 to 2019, the rate of Corps). These include clinical prevention efforts that are generally focused on suicide increased from 20.4 to 25.9 per individual patient treatment and interventions, as well as non-clinical efforts that 100,000 active component are intended to reduce the risk of suicide in the military population. This includes, servicemembers. Over the past for example, training servicemembers to recognize warning signs for suicide and decade, DOD has taken steps to encouraging the safe storage of items such as firearms and medications. address the growing rate of suicide in the military through efforts aimed at Officials with DOD’s Defense Suicide Prevention Office (DSPO) told GAO that prevention. most ongoing non-clinical efforts are evidence based. Officials added that a suicide prevention effort is considered to be evidence based if it has been The National Defense Authorization Act for Fiscal Year 2020 included a assessed for effectiveness in addressing the risk of suicide in the military provision for GAO to review DOD’s population, which has unique risk factors such as a higher likelihood of suicide prevention programs. This experiencing or seeing trauma. These officials stated that newer efforts are report examines DOD’s suicide generally considered to be “evidence informed,” which means that they have prevention efforts, including, among demonstrated effectiveness in the civilian population, but are still being assessed other objectives, (1) the extent to which in the military population. non-clinical efforts are assessed for DSPO officials further explained that assessments of individual prevention efforts being evidence based and effective can be challenging because suicide is a complex outcome resulting from many and (2) any impediments that hamper interacting factors. In 2020, DSPO published a framework for assessing the the effectiveness of these efforts. collective effect of the department’s suicide prevention efforts by measuring GAO examined suicide prevention outcomes linked to specific prevention strategies, such as creating protective policies, reports, and assessments and environments. However, this framework does not provide DOD with information interviewed officials from DOD, the on the effectiveness of individual non-clinical prevention efforts. Having a military services, and the Reserve process to assess individual efforts would help DOD and the military services components. GAO also interviewed ensure that their non-clinical prevention efforts effectively reduce the risk of officials at four installations and a suicide and suicide-related behaviors. National Guard site selected for variety in military service, location, and size. GAO also identified impediments that hamper the effectiveness of DOD’s suicide prevention efforts, including those related to the reporting of suicide data. What GAO Recommends • Definitions. The military services use different definitions for key suicide- GAO recommends that (1) DSPO and related terms, such as suicide attempt, which may result in inconsistent the military services develop a process classification and reporting of data. These data are used to develop the to ensure that individual non-clinical department’s annual suicide event report. DOD officials stated that this could suicide prevention efforts are assessed negatively affect the reliability and validity of the reported data, which may for effectiveness, (2) DSPO and the military services work together to impede the department’s understanding of the effectiveness of its suicide develop and use consistent suicide- prevention efforts and limit its ability to identify and address any related definitions, and (3) DOD shortcomings. improve collaboration on its annual suicide reports to reduce duplication of • Annual suicide reports. DOD publishes two yearly suicide reports through effort. DOD concurred with all of two different offices that are based on some of the same data and provide GAO’s recommendations and identified some of the same information, resulting in the inefficient use of staff. While actions it will take to implement them. these reports serve different purposes, improved collaboration between the two offices could help minimize duplication of effort and improve efficiency, View GAO-21-300. For more information, potentially freeing resources for other suicide prevention activities. contact Debra A. Draper at (202) 512-7114 or [email protected]. United States Government Accountability Office Contents Letter 1 Background 6 While DOD Estimates That Most of Its Non-clinical Suicide Prevention Efforts Are Evidence Based, Not All Have Been Assessed for Effectiveness in the Military Population 11 Mental Health Care Access Issues and Inconsistent Data Definitions and Reporting May Hamper the Effectiveness of the Department’s Suicide Prevention Efforts 14 Limited Access to Military Resources and Difficulties Collecting Data May Additionally Hamper Suicide Prevention Efforts for Reserve Components 22 Conclusions 24 Agency Comments 24 Appendix I Examples of Non-clinical Suicide Prevention Efforts in the Department of Defense 26 Appendix II Comments from the Department of Defense 29 Appendix III GAO Contact and Staff Acknowledgments 31 Tables Table 1: Examples of Centers for Disease Control (CDC) Suicide Prevention Strategies and Associated Department of Defense (DOD) Prevention Efforts, Proximal Outcomes, and Baseline Metrics 13 Table 2: Department of Defense (DOD) and Military Service- Specific Definitions for Suicide Attempt 18 Table 3: Defense Suicide Prevention Office’s List of Non-clinical Suicide Prevention Efforts across the Department of Defense (DOD) and Military Services 26 Figures Figure 1: Offices within the Department of Defense (DOD) Involved with Suicide Prevention Efforts 7 Figure 2: National Guard Organizational Structure 9 Page i GAO-21-300 DOD Suicide Prevention Abbreviations CDC Centers for Disease Control and Prevention DHA Defense Health Agency DOD Department of Defense DODSER Department of Defense Suicide Event Report DSPO Defense Suicide Prevention Office NDAA National Defense Authorization Act This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. Page ii GAO-21-300 DOD Suicide Prevention Letter 441 G St. N.W. Washington, DC 20548 April 26, 2021 The Honorable Jack Reed Chairman The Honorable James M. Inhofe Ranking Member Committee on Armed Services United States Senate The Honorable Adam Smith Chairman The Honorable Mike Rogers Ranking Member Committee on Armed Services House of Representatives Suicide is a public health problem facing all populations, including the military, which comprises active component servicemembers in each of the military services (Army, Navy, Air Force, and Marine Corps), and members of the Reserve components (National Guard and Reserves).1 Suicide has been a growing concern for the Department of Defense (DOD). In its 2019 Annual Suicide Report, the department stated that the suicide rate for active component servicemembers continued to increase over the past 5 years, reaching 25.9 per 100,000 in 2019.2 The report also noted that military suicide rates for both active component 1The National Guard includes the Army National Guard and the Air National Guard. The Reserves include the Army Reserve, the Navy Reserve, the Marine Corps Reserve, the Air Force Reserve, and the Coast Guard Reserve. However, because our review is focused on the Department of Defense, we did not include the Coast Guard Reserve, which is part of the Department of Homeland Security. 2Department of Defense, Under Secretary of Defense for Personnel and Readiness, Annual Suicide Report: Calendar Year 2019 (October 1, 2020). Between 2014 and 2019, the suicide rate for active component servicemembers increased by 27 percent, 20.4 to 25.9 per 100,000. Page 1 GAO-21-300 DOD Suicide Prevention servicemembers and the National Guard were comparable with that of the U.S. adult population.3 DOD has taken steps to address the growing rate of suicide in the military. Specifically, in 2011, DOD established the Defense Suicide Prevention Office (DSPO) to develop and oversee standardized policies, procedures, and surveillance activities for the department’s suicide prevention efforts aimed at reducing the risk of suicide in the military population.4 As part of its duties, DSPO has developed the Defense Strategy for Suicide Prevention, as well as policies that, for example, establish department-wide responsibilities for suicide prevention
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