Investigation Proves Whistleblower Claims – VA Neglected some Suicidal Veterans
note: This Blogmaster is aware of one veteran who previously attempted suicide and sought help from VA mental health facilities and was instead invited to an afternoon veterans' picnic, with no professional follow-up. Claims of depression brought prescriptions for Prozac from a primary care provider.
The Department of Veterans Affairs has substantiated some of the allegations made last year by a former epidemiologist who claimed that the agency neglected assisting suicidal veterans and was slow to release important research data.
The former employee, Dr. Steven S. Coughlin, was a principal investigator at the VA’s Office of Public Health until resigning in December 2012. Coughlin testified in March 2013 before an investigative and oversight panel of the House Committee on Veterans’ Affairs. (See “Whistleblower Accuses Government Of Neglecting Suicidal Veterans And Suppressing Science”.)
The VA’s Office of Research and Oversight investigated Coughlin’s claims and completed a report on its findings last summer. It did not brief Congressional staff of the House Committee on Veterans’ Affairs on its report until January, according to Chairman Rep. Jeff Miller (R-Fla.).
After interviewing several VA staff and reviewing 3,000 pages of relevant documentation, the investigators substantiated three of 10 allegations made by Coughlin:
· VA lost medical data obtained from the children and spouses of Gulf War veterans that might have demonstrated an association between illnesses, including those related to wartime exposure, in service members and their offspring;
· Coughlin’s superiors responded to his concerns in a way that could have been perceived as threatening or retaliatory;
· VA neglected to contact participants in a study of Gulf War veterans who shared suicidal thoughts or feelings.
Regarding Coughlin’s other claims, the investigators often said the disagreements between Coughlin and his superiors resulted from conflicting priorities.
While Coughlin, for example, said his supervisors were deliberately withholding important data regarding exposure of Iraq and Afghanistan veterans to toxins and inhalation hazards, those interviewed about the claim said the data needed to be cleaned and that analysis should focus on the main subjects of the study, which are traumatic brain injury and post-traumatic stress disorder. The report urges VA to complete the analyses “as expeditiously as possible.”
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Coughlin, who is now a professor of preventive medicine at the University of Tennessee in Memphis, claimed that the decision to report his concerns took a toll on him professionally and personally. “I quit my job and left because it wasn’t just one ethical problem, it was a whole constellation,” he said. “I finally had enough.”
He remains concerned that veterans participating in different VA studies who expressed suicidal feelings have not or may still not get a follow-up call from a mental health provider. Before he left VA, he was eventually permitted to involve clinicians in a 20-year study of 30,000 Gulf War veterans. A team of social workers and psychologists placed follow-up phone calls to nearly 100 veterans who had reported suicidal behavior. The report found that a smaller group of veterans participating in a separate study required follow-up; six veterans were subsequently contacted.
Coughlin’s supervisors told investigators that they had not rushed to develop a plan for contacting suicidal veterans because they felt doing so “represented a desirable innovation, rather than an immediate need.” They also worried that calling veterans would violate privacy and confidentiality guarantees and “thereby undermine Veterans’ trust in future [Office of Public Health] surveys.”
Since the investigation concluded, VA has taken several steps to address Coughlin’s substantiated claims.
Dr. Tom Puglisi, executive director of the Office of Research Oversight at the Veterans Health Administration (VHA), said in a statement that the “evolving standard is that participants demonstrating suicidal ideation in research studies should be contacted promptly for clinical follow-up, and VHA expects that future [Office of Public Health] surveys will adhere to this standard.”
The report recommends increased Institutional Review Board oversight for research conducted by the agency. Office of Public Health supervisors have participated in human resources training in conflict resolution. That office has also established timelines for analyzing and publishing data from major studies on Gulf War, Iraq and Afghanistan veterans, including results that might indicate a neurological explanation for Gulf War Illness.
In a statement, the agency acknowledged the results of the investigation and said the its “highest priority” is the mental health of veterans.
“The Department of Veterans Affairs recognizes and respects the service, dedication and many challenges of Veterans of the 1990-1991 Gulf War, and is committed to improving the health and well-being of these Veterans,” Puglisi said. “Research is a vital component in improving that treatment.”