bullying at veterans affairs case study

Exposure to Bullying or Hazing During Deployment and Mental Health Outcomes Among US Army Soldiers

Affiliations.

• 1 Department of Psychiatry, University of California, San Diego, La Jolla.
• 2 Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla.
• 3 Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.
• 4 Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
• 5 Veterans Affairs San Diego Healthcare System, San Diego, California.
• PMID: 36692883
• PMCID: PMC10408263
• DOI: 10.1001/jamanetworkopen.2022.52109

Importance: Workplace bullying is associated with mental disorders and suicidality in civilians, but few studies have examined associations of bullying with these outcomes among military personnel.

Objective: To evaluate associations of being bullied or hazed during deployment with major depressive disorder (MDD), intermittent explosive disorder, posttraumatic stress disorder (PTSD), suicidal ideation, and substance use disorder (SUD).

Design, setting, and participants: This cohort study used data from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) New Soldier Study (NSS; April 1, 2011, to November 30, 2012) and wave 1 of the STARRS Longitudinal Study (STARRS-LS1; September 1, 2016, to April 30, 2018). A computerized survey administered at 3 US Army installations (NSS) and a web/telephone survey (STARRS-LS1) were used to collect data. Data were analyzed from October 11, 2021, to October 28, 2022. The STARRS-LS1 recruited a probability sample of active-duty soldiers and veterans who had participated in Army STARRS baseline surveys while on active duty (weighted response rate, 35.6%). Respondents whose baseline was the NSS and who had deployed to a combat theater at least once were eligible for this study.

Exposures: Being bullied or hazed during a combat deployment.

Main outcomes and measures: The primary outcomes were MDD, intermittent explosive disorder, PTSD, and suicidal ideation in the 12 months before STARRS-LS1 and SUD in the 30 days before STARRS-LS1, assessed with items from the Composite International Diagnostic Interview Screening Scales, PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and Columbia-Suicide Severity Rating Scale. Logistic regression was used to estimate associations of bullying or hazing exposure with the outcomes.

Results: The 1463 participants were predominantly male (weighted percentage [SE], 90.4% [0.9%]) and had a mean (SE) age of 21.1 (0.1) years at baseline. At STARRS-LS1, 188 respondents (weighted percentage [SE], 12.2% [1.1%]) reported bullying or hazing during deployment. Weighted outcome prevalences were 18.7% (1.3%) for MDD, 5.2% (0.9%) for intermittent explosive disorder, 21.8% (1.5%) for PTSD, 14.2% (1.2%) for suicidal ideation, and 8.7% (1.0%) for SUD. In models that adjusted for baseline sociodemographic and clinical characteristics and other potential traumas, exposure to bullying or hazing was significantly associated with MDD (adjusted odds ratio [aOR], 2.92; 95% CI, 1.74-4.88), intermittent explosive disorder (aOR, 2.59; 95% CI, 1.20-5.59), PTSD (aOR, 1.86; 95% CI, 1.23-2.83), suicidal ideation (aOR, 1.91; 95% CI, 1.17-3.13), and SUD (aOR, 2.06; 95% CI, 1.15-3.70).

Conclusions and relevance: In this cohort study of combat-deployed soldiers, reports of being bullied or hazed during deployment were associated with mental disorders and suicidal thoughts. Recognition of these associations may inform efforts to prevent and address mental health problems among service members.

Publication types

• Research Support, N.I.H., Extramural
• Research Support, U.S. Gov't, Non-P.H.S.
• Cohort Studies
• Depressive Disorder, Major* / epidemiology
• Longitudinal Studies
• Military Personnel*
• Outcome Assessment, Health Care
• Risk Factors
• Suicide, Attempted
• Young Adult

Grants and funding

• U01 MH087981/MH/NIMH NIH HHS/United States

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Criminal Justice Collaborative

For va whistleblowers, a culture of fear and retaliation.

Eric Westervelt

Employees at the Central Alabama Veterans Health Care System in Montgomery, Ala., say they face retaliation when reporting mismanagement or abuse. Eric Westervelt/NPR hide caption

Employees at the Central Alabama Veterans Health Care System in Montgomery, Ala., say they face retaliation when reporting mismanagement or abuse.

Alan Hyde is a veteran of the U.S. Marine Corps and the Central Alabama Veterans Health Care System. He served in Operation Desert Storm, where he suffered an in-service leg injury. But it's his time with the Central Alabama VA, he says, that has left him more rattled, frustrated and angry.

"It's a toxic environment there," Hyde says. "And I feel sorry for the veterans."

Hyde is both a patient and a former employee at the Central Alabama Veterans Health Care System in Montgomery. He supervised employees who took vets for treatment outside the VA. Hyde was fired after six months for unspecified misconduct. He is among dozens of people who say they faced vicious retaliation when they tried to improve conditions there or hold managers accountable.

More than 30 current and former VA employees spoke to NPR. They include doctors, nurses and administrators — many of them veterans themselves. All describe an entrenched management culture that uses fear and intimidation to prevent potential whistleblowers from talking.

Leslie Wiggins during a hearing at Georgia State University in Atlanta on Aug. 7, 2013. The hearings held by Sen. Johnny Isakson, R-Ga., examined a report outlining alleged mismanagement at the Atlanta Veterans Medical Center before Wiggins was hired. John Bazemore/AP hide caption

"If you say anything about patient care and the problems, you're quickly labeled a troublemaker and attacked by a clique that just promotes itself. Your life becomes hell," one longtime employee at the Central Alabama Veterans Health Care System , or CAVHCS, told NPR. Like many we interviewed there, she requested anonymity out of fear for her job.

Part 1: An Entrenched Culture Of Vicious Retaliation

Investigation into the va reveals a culture of retaliation against whistleblowers, part 2: can the va police itself.

The problems are especially acute at hospital complexes in Montgomery and Tuskegee, Ala., which are part of a regional network known as VA Southeast Network VISN 7. The Department of Veterans Affairs divides veterans' health care into 21 geographic regions called VISNs.

Workers say the retaliatory tactics run the gamut from sophomoric (a shift manager pouring salt into a subordinate's coffee cup) to hard-to-fathom (isolation rooms used as psychological coercion) and more.

"There's no accountability," Hyde says. "And it's gonna be a never-ending cycle here until someone steps in and starts cleaning house from the top and putting people in who care about the veterans."

But neither those charged with federal oversight nor the VA itself has taken those steps, months or even years after the first complaints were reported.

Whistleblowers

Hyde, a U.S. Marine Corps veteran, is both a patient and former employee of the Central Alabama VA. "It's a toxic environment there," he says.

Cynthia Chavez

Chavez, a retired U.S. Army colonel, was forced out as head of food and nutrition in Montgomery and Tuskegee after an impeccable career in the Army and the VA.

Dr. Julian Kassner

Kassner is a U.S. Navy-trained physician. He was hired by the Central Alabama VA to clean up the radiology department.

Sheila Walsh

Walsh was HR director and a 20-year U.S. Army veteran. She says she was retaliated against when she questioned the treatment of whistleblowers.

VISN 7 leads the VA in the number of whistleblower complaints per veteran served. The VA itself leads all federal agencies in the number of whistleblowers who say they've been retaliated against — up to 40 percent annually, according to federal testimony . Two nonprofit groups that support whistleblowers say the number of retaliation cases they see from the VA is far higher.

In the case of Central Alabama, NPR's investigation found that senior leadership subjected employees who spoke up to similar patterns of punishment:

• Physical isolation and verbal abuse.
• Bullying in and outside the workplace.
• Counter-investigations that blamed the employees for creating a "hostile work environment" or other vague and often unspecified charges.

Why are conditions so bad in Central Alabama? Watchdog groups and affected workers believe it's a combination of weak, inconsistent enforcement of whistleblower protection laws, a senior managerial culture that practices and condones bullying, and a VA system that too often sends whistleblower grievances right back to regional managers who are often part of the original complaints.

The scope of the retaliation and sheer number of retaliation complaints in VISN 7 and across the agency raise questions about whether the VA can adequately police itself and embrace whistleblowers as President Trump and the VA have vowed to do.

Stealing food from vets

"I hadn't been there [Central Alabama] two weeks when an employee came in to tell me about illegal activities in the kitchen, and he stopped right there and he said, 'But if you're not going to do anything about it, I'm going to keep my mouth shut, otherwise I become the target,'" says retired U.S. Army Col. Cynthia Chavez.

Chavez has some 50 years of combined Army active duty, Reserve and VA service. She has consistent outstanding or exceptional performance reviews across both institutions.

In June 2014, she was hired to lead Nutrition and Food Services for Central Alabama's VA. She soon found that both the Montgomery and Tuskegee hospital kitchens — especially Tuskegee's — had serious, systemic problems.

Some employees, she says, routinely came in late, left early or didn't show up at all. One, she says, would openly drink on the job. That employee once told a veteran in a PTSD program, " 'I'll give you the bullet to put in the gun to shoot yourself,' " she says.

Veterans Groups Concerned That Lack Of VA Leadership Will Hurt Millions Of Veterans

Remarkably, that wasn't the worst of it.

Chavez was told that a longtime employee was allegedly running a side catering business out of the VA kitchen in Tuskegee.

"She was using government employees, government food, on government time, for her catering business," Chavez says. "She was selling it [food] through her catering business" to area companies and churches. "And so when I did my due diligence, sure enough, she couldn't answer questions about how she'd catered this event and yet she was on duty."

One Valentine's Day, for example, a case of steaks and cheesecakes meant for a special hospital meal for vets went missing. Several co-workers told Chavez the thievery had been going on for years.

Chavez was shocked and moved quickly to investigate and temporarily suspend the employee , emails and documents show. She also imposed stronger discipline and order on a hospital kitchen she says "was like the Wild West. They [employees] did what they wanted to." All the food in the kitchen is from appropriated funds meant only for veterans in hospital treatment. "Myself, as a 30-year veteran, I couldn't even eat there."

Soon after, Chavez got the first of many anonymous-threat letters slipped under her Tuskegee office door. "This isn't the Army, where you had connections. This is the VA and we will get you," one letter said.

But Chavez says that the anonymous-threat letters were only slightly more menacing than what she soon got from her boss and the local union leaders.

Following an almost classic whistleblower retaliation script, instead of support, Chavez was soon investigated for "abuse of authority" and "creating a hostile work environment."

The union, Tuskegee AFGE Local 110, quickly announced it had taken a vote of "no confidence" in Chavez.

And her top boss, a career VA employee named Leslie Wiggins , soon told her in no uncertain terms to back off.

In fact, Wiggins then took charge of all discipline and oversight of the VA's troubled hospital kitchen. She also stripped Chavez of all the authority and oversight she had been hired to impose on the department. The reason given, emails and documents show, was Chavez's "inappropriate disciplinary actions" against the food service staff.

When a local union official complained that Chavez was issuing what he called "unsubstantiated" AWOLs, or absent without leave sanctions, Wiggins — then serving as acting director of CAVHCS as well as head of VISN 7 — emailed Chavez: "This is a very disturbing email" about what "may be a problem practice" of issuing AWOLs. "So until further notice," Wiggins wrote, "there are to be NO AWOL's issued until I review them."

"I am trying to hold employees accountable and all I get is pushback through anonymous letters," Chavez says. "And even when HR was saying, 'No, she's justified in what she's trying to do,' they would not let me take any discipline against anything that the employees were doing."

She notified federal offices that she was the target of whistleblower retaliation. Nothing, so far, has come of it. Chavez eventually went out on medical leave to care for her cancer-stricken husband.

This past January, Chavez's boss and Central Alabama's director, Linda Boyle , emailed her: "The decision has been made to terminate you effective January, 30, 2018."

Chavez's request to be allowed to retire at the end of March and to use her remaining sick leave to help her husband was denied. She reluctantly retired.

Despite several Freedom of Information Act requests, Chavez has never seen details of the charges brought against her in what's known as an Administrative Investigation Board (AIB).

The woman who was allegedly stealing food from veterans for years through her side catering business? She was allowed to retire with full benefits. There's no indication she was ever disciplined by the VA or the local union.

Neither Wiggins nor Boyle would comment on Chavez's case or the wider pattern of retaliation.

"Mafia culture"

Dr. Julian Kassner, a former lieutenant commander, is a Navy-trained physician with a stellar record. The Central Alabama VA hired the native New Yorker in 2016 to clean up a deeply troubled radiology department that had been embroiled in a 2014 scandal involving falsified records and substandard care. More than 2,000 X-rays of veterans went unread over a five-year period.

Kassner, interviews with his former subordinates show, worked fast to try to clean up the department. His radiology co-workers liked that he was taking charge. He got a good performance review from his immediate boss and was even tasked with helping to implement radiology improvements across the Southeast district.

Then suddenly, he found himself the target of an investigation and workplace retaliation.

" I was absolutely shell-shocked," Kassner says, "and initially my thinking was, 'Well, I have no idea what this is about, but hopefully it'll get sorted out in a day or two.'"

He immediately sent a letter requesting clarification as to what exactly he'd been accused of and an opportunity to respond.

Soon after, Kassner, like other whistleblowers in VISN 7, was isolated — literally — in a remote room. He was ordered not to talk with colleagues or access documents while the investigation unfolded.

To be closer to his family in neighboring Florida, Kassner's contract allowed him to read medical images remotely part of the time, a common practice in radiology. The Montgomery leadership began to use that telework agreement against him and ordered him on site full time.

Senate Passes $55 Billion Veterans Affairs Reform Bill

During the initial days of retaliation, he thought he was going crazy.

But he wasn't. Audio of a meeting between two HR officials in Montgomery and Dr. Randall Weaver, then the acting chief of staff at the hospital there, describes the VISN leadership's alleged view of Kassner.

In the audio, Weaver says he hopes Kassner quits because if he comes back from sick leave, Atlanta VA leaders in VISN 7 will surely find any way to fire him.

"The thing for him, because of his situation where they're gonna — people will be after you again no matter what you do, even if you sneeze wrong they're gonna get you," Weaver says. He adds that because of Kassner's brusque personality, "it's easy to get stuff on him," meaning to get people to turn against him.

Weaver did not respond to NPR's request for comment.

The actions alarmed Sheila Walsh, the director of human resources for the Central Alabama VA.

"That's what made me feel so sick to my stomach, I mean because that's all code for they're going to target him," says Walsh, who made the recording. She routinely taped meetings under a disabilities act health accommodation.

Kassner was soon fired from CAVHCS. He was never given a reason. Documents show that the Alabama VA has stonewalled his attorney's efforts to uncover evidence.

For Kassner, the audiotape, the emails and the scores of documents — all of which he has turned over to federal investigators — underscore what he and others call a deeply troubling "mafia culture" at CAVHCS and VISN 7 leadership.

"Toxic, dysfunction and out of control is an understatement. There are people at the senior level there that consider themselves the equivalent of a 'made man' in the mafia, that there are no rules that apply to them up to and including fraud and record falsification," he says. "How this is allowed to go on is just mind boggling."

His case may have another serious wrinkle. Kassner says he has evidence that his federal pay and employment records were altered by someone in Central Alabama. He says they falsely show he was "separated" from the VA before the end of his two-year probationary period, a key legal time frame for a federal employee because of work rules and benefit eligibility. They listed income after his probationary period, Kassner points out, as "deferred income" from a previous year. "It's record falsification pure and simple," he says.

HR director targeted

Remember Sheila Walsh, the head of the VA's Central Alabama human resources division? The CAVHCS and VISN 7 leadership went after her, too.

As HR director, Walsh, a 20-year Army vet, stood up for Chavez, for Kassner and, documents show, for several other Alabama whistleblowers she believed were facing unjust treatment and illegal retaliation.

After Walsh had told superiors, yet again, that the case against Kassner was legally and morally suspect, her supervisor Leslie Wiggins emailed her to "stand down."

" I went on the record [with her supervisors] saying I'm not going to participate in this level of corruption, illegal actions," Walsh says. "And so I became the enemy. Instead of them investigating the wrongdoings, they started investigating me."

The retaliation also included intimidation and four weeks of isolation. Like Kassner, Chavez and the others, she was assigned to an isolated office and told not to communicate with fellow staffers or access documents while the investigation unfolded.

"They wanted me to feel humiliated," Walsh says, "trying to break me down. And they did break me down."

A CAVHCS supervisor took away her office keys and even took possession of her Army service medals, military command coins and an American flag in a case that she got for 20 years of honorable military service, as well as family photos. Walsh believes taking control of her personal possessions was clearly part of the retaliation.

"It's a kind of psychological violence," she says, tearing up over the loss of her Army service mementos. "I feel violated. I feel like someone robbed me."

CAVHCS has, so far, ignored her efforts to get those personal military items returned. She has even appealed to the House Committee on Veterans' Affairs to get her military items back. So far, there has been no action.

These retaliatory tactics in Alabama follow a clear pattern: Employees who flag problems or wrongdoing are quickly counter-investigated — almost always charged with creating "a hostile work environment" or other vague charges. Then the employee is isolated – literally.

"Basically we call it putting the whistleblowers in professional solitary confinement," says Tom Devine, legal director of the Government Accountability Project . He says it's a tactic long used by some VA managers to try to crush whistleblowers. "Keep them away from the evidence, make them pariahs among their peers. Make an example out of them. Generally the rooms where these people are assigned to bounce off the walls without duties are unheated in the winter and uncooled in the summer. It's like putting somebody in a hot box."

Senior VA leaders in Alabama and Atlanta declined to answer questions about the alleged pattern of retaliation, corruption and mismanagement.

The director of the VA Southeast Network VISN 7 – Leslie Wiggins — refused multiple interview requests through three different spokespersons.

The current director of Central Alabama's VA, Linda Boyle , also refused multiple interview requests through spokespeople.

Jan Northstar, the VA's Southeast District public affairs director, said by email that they cannot discuss individual cases without written consent. She added the "VA does not tolerate retaliation. Any employee who feels he or she is experiencing retaliation should contact the Office of Accountability and Whistleblower Protection."

Like Chavez, Kassner and scores of others we talked with in Alabama, former HR director Walsh has, in fact, filed formal complaints with the VA's own Office of Accountability and Whistleblower Protection , as well as with the federal Office of Special Counsel, the federal Merit Systems Protection Board and other offices.

Walsh's doctor says she has a form of PTSD from the VA experience. The HR director remains out on unpaid medical leave after exhausting her annual leave.

Walsh and the others want those federal bodies or Congress itself to take bold action to change the years-long pattern of retaliation.

So far, their cases have been largely met with inaction, silence or indifference.

One whistleblower wins

VISN 7's director Leslie Wiggins, in fact, has had numerous whistleblower retaliation complaints filed against her, including one by an employee in her immediate office in Atlanta. The federal Office of Special Counsel ruled against Wiggins and her office in a case that, as the Atlanta Journal-Constitution put it , showed that the Atlanta VA seemed more preoccupied with halting bad press coverage than stopping a series of veteran suicides in the Atlanta area.

Retired Army Sgt. Maj. Greg Kendall, a 30-year veteran with tours in Iraq and Afghanistan, took a job as a public affairs officer (PAO) in the Atlanta VA after his military service. Kendall says he raised concerns about spending tens of thousands of taxpayer dollars promoting a local charity gala that senior VA employees planned to attend. At the time, the Atlanta office was under fire for underfunding and understaffing veteran mental health services, including suicide prevention efforts.

"The leadership was not interested in my concerns and basically told me to mind my own business," Kendall says.

When the charity story went public, the Atlanta management quickly gave him a bad evaluation, placed him on a performance improvement plan, and, following the pattern, isolated him in a small, shabby, vacant patient room while he was "investigated."

"The entire leadership team knew that I was in that patient room for almost a year that could have been used for veteran care," Kendall says, but "they were more concerned about retaliation than taking care of veterans."

Kendall fought back, filing for whistleblower protection. The federal Office of Special Counsel (OSC) investigated and ruled in Kendall's favor, saying he had been targeted and punished for speaking up.

"Mr. Kendall did the right thing by raising concerns about an inappropriate expenditure of taxpayer dollars, but the Atlanta VA failed to heed his warnings and instead targeted Mr. Kendall," the Special Counsel's Carolyn Lerner wrote in the OSC ruling. Lerner added that "the VA must continue working to make its culture more welcoming to whistleblowers in all of its facilities."

Kendall says he blew the whistle after thinking about the vets he served with in Iraq and Afghanistan.

"They depend on the VA," he said. "So the very fact that we (Atlanta VA) have been cited for mismanagement that led to suicides told me that we needed to do something to make sure that that didn't happen again."

His case is one of the only whistleblower cases to succeed against VISN 7 leadership.

Can the VA police itself?

Nearly a year ago, the VA reorganized the unit responsible for protecting workers who call out wrongdoing, waste, fraud and abuse. In that 11-month period, the new Office of Accountability and Whistleblower Protection (OAWP) has received 120 whistleblower complaints from VISN 7: the most complaints of retaliation per veteran served of the department's 21 VISNs.

Only VISN 22 (Southern California, Arizona and New Mexico) and VISN 8 (Florida, Puerto Rico and the U.S. Virgin Islands) had similar numbers, but both serve a larger number of veterans. VISN 8, for example, had about 1.5 times as many completed veteran appointments in 2017, according to the VA's own patient access data.

Whistleblower Sheila Meuse was a VA hospital administrator who helped expose mismanagement in Central Alabama. She now sells real estate in Montgomery, Ala. Eric Westervelt/NPR hide caption

Whistleblower Sheila Meuse was a VA hospital administrator who helped expose mismanagement in Central Alabama. She now sells real estate in Montgomery, Ala.

Of those 120 complaints against VISN 7, 79 were determined to be of "reasonable belief" and 51 investigations were opened.

Yet only 11 of those 51 are currently under investigation by OAWP. The other 40 were sent back to VISN 7 or district level for investigation.

It's exactly that investigatory boomerang, critics say, that highlights why the VA is so ineffectual at policing whistleblower retaliation.

For example, emails from Walsh, the HR executive, show that during her last contact with OAWP, the office told her that her case was under investigation. But Walsh hasn't heard from OAWP in more than eight months.

"No calls, no emails, no texts, nothing. It's like we don't exist," she says.

VA spokeswoman Ashleigh Barry said the OAWP would not comment on active investigations or allegations of worker retaliation at VISN 7, but said the department takes all allegations seriously.

The Accountability and Whistleblower Protection Act expanded the authority and support for the OAWP, the VA's office that now shares the bill's name .

But a year later, there's skepticism the OAWP is living up to its name.

"We've got a very sick organization. The important thing (for the VA) is to squelch the whistleblowers to speak. You know, it's like shoot the messenger because it's not the message we want to hear," says VA whistleblower Sheila Meuse, who has 30-plus years of federal service — almost all of it at VA facilities across the country.

Meuse rose from a clinician to, in 2014, serving briefly as the third in command at Central Alabama. "I always had either outstanding or exceptional ratings," she says. "I can't remember any one rating ever that was below exceptional in my career history."

Just four months into her new job in Alabama, Meuse and her direct boss, Richard Tremaine, exposed unethical practices — part of that wait-times scandal in 2014 that played out in multiple VA hospitals across the country.

Central Alabama has long had other, well-documented problems. CAVHCS was investigated by the Office of Inspector General , which confirmed it had some of the worst wait times in the country.

VISN 7 was recently cited for failing "vulnerable veterans" by not adequately providing and repairing wheelchairs and scooters for disabled service men and women. Also, in 2017 a Navy veteran with dementia wandered away from the Tuskegee VA dementia unit. He was never found.

But the wait-time scandal in Alabama also involved misconduct, negligence and cover-up: several thousand veteran X-rays were never read , and one VA employee in Tuskegee took a veteran in recovery to a crack house to buy drugs. The employee even charged the VA several hundred dollars in overtime pay for the drug-buying binge.

Meuse and Tremaine, gave inspectors evidence that the then-director had known about cooking the wait time books for at least a year. That CAVHCS director, James Talton, was eventually fired for neglect of duty.

Yet, lost in all that scandal was what happened to whistleblowers Tremaine and Meuse.

"We were excluded, we were yelled at. I was detailed to another facility. I was met by nothing but retaliation, resistance and shunning," Meuse says. "It was just a horrible, horrible experience. Totally a nightmare."

The Atlanta VA director launched an administrative probe of them. They were isolated and stripped of duties. Atlanta wanted to know if the two whistleblowers had behaved in a way consistent "with the VA's core values."

Tremaine took a senior management job at a VA hospital in Colorado. Meuse left the VA. She now sells real estate around Montgomery.

Tremaine believes the genesis of CAVHC's deep problems "has a lot to do with nepotism and an overall lack of real commitment to fix things by a minority of people who've maintained control and leadership" despite numerous investigations and a flood of complaints. "We [whistleblowers] should really have a T-shirt that says 'I Survived CAVHCS.' "

Improving VA management and protecting workers who speak up was one of President Trump's campaign pledges.

"Those entrusted with the sacred duty of serving our veterans will be held accountable for the care they provide," the president said at a VA reform bill signing ceremony last year. "At the same time, this bill protects whistleblowers who do the right thing. We want to reward, cherish, and promote the many dedicated employees at the VA."

Meuse is not convinced the newly rebranded whistleblower protection office can fix what she calls an abusive ethos that runs deep in some parts of the VA, especially in Alabama.

" I don't think naming an office is how you fix an organizational culture that is really rancid and full of cronyism, favoritism; the old guard that takes care of themselves to maintain the status quo instead of caring for veterans," she says.

Many watchdog groups agree. The complaints about President Trump's newly created office include that it's understaffed and that investigations drag on.

But the biggest critique is that the whistleblower protection office or OAWP can't really enforce its findings.

"I've been impressed that the new OAWP is actually making a good faith effort. But they don't have any teeth to their good faith," says Tom Devine with the nonprofit Government Accountability Project .

He says the office is staffed by people whose hearts are in the right place. But "until they get some enforcement teeth, all they are going to be is background noise. And right now the situation at the VA is, by far, the most intolerable in the [federal] government."

Devine says numbers to his office show that about 40 percent of all whistleblower retaliation complaints from the entire U.S. government come from the VA. Federal testimony supports those numbers.

Central to the problem is that whistleblowers' retaliation complaints can often end up being handled by the very people accused of doing the retaliation. In Alabama and Georgia, as we've shown, it's a common tactic to open up a counter-investigation of the worker who raises issues. That often includes nebulous charges that the whistleblower is creating a "hostile environment."

"I haven't heard anyone tell me that when they've gone to this office of accountability that they've actually been assisted," says Jackie Garrick, the founding director of the independent group Whistleblowers of America .

Garrick says at least 80 percent of all cases that come into her office are from VA employees.

In fact, tensions within the VA over whistleblowers came to light when a congressman released correspondence this week.

In a strongly worded letter, the VA's Inspector General (OIG) voiced deep concern that the OAWP is failing to turn over key records and information about the 150 to 170 employee retaliation complaints that office receives every month.

The inspector general is the VA's oversight body tasked with audits, investigations and detecting waste, abuse and mismanagement.

VA Inspector General Michael J. Missal wrote that "despite repeated assurances that these records would be made available, the OIG has not yet been provided this important information." Missal added that "it does not appear that an appropriate number of complaints have been referred to the OIG."

Peter O'Rourke, the acting secretary of Veterans Affairs, who until recently headed the whistleblower protection office, fired back accusing the OIG of "abuse of authority" and mismanagement. O'Rourke said the OIG was "not performing its responsibilities in a fair and objective manner, which has caused significant harm to the reputation and performance of VA and its employees."

Minnesota Democrat Tim Walz, a ranking member of the House Committee on Veterans' Affairs, blasted O'Rourke's letter to Missal, calling it intimidation and "not in the best interest of America's veterans."

In response to the dispute, VA spokesman Curt Cashour wrote that "giving the IG unfettered access to OAWP whistleblower case files could make whistleblowers vulnerable to retaliation, place a chilling effect on future disclosures and lead to the same sort of problems whistleblowers and the Office of Special Counsel have criticized the IG for in the past."

Whether the VA can be fair and objective while investigating itself will be one key challenge for President Trump's pick to lead the VA, nominee Robert Wilkie Jr., who faces confirmation hearings later this year.

• whistleblowers
• U.S. Department of Veterans Affairs

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Veterans' affairs under culture review over 'toxic' bullying allegations, resignations.

Workers at Veterans' Affairs have lodged official complaints that bullying is so bad they feel suicidal.

Photo: 123RF

At least five complaints were made to workplace safety regulator WorkSafe as early as May.

It has not begun a formal investigation, but asked the Defence Force to review the "workplace culture" at its semi-autonomous, 80-person VA unit.

Defence says it will do this, "supported by the Veterans' Affairs leadership team" - even though that team is the subject of some of the complaints.

The Public Service Association questions why there is no independent investigation.

The PSA union says it knows of at least five workers who have quit over the bullying in the last year.

"They feared for their futures and their own state of mind and wellbeing ... people were fearful of going to the job," the Public Service Association union's Defence organiser Mark James said.

"They felt suicidal."

People dreaded coming to work for fear of intimidation and discrimination, which came to a head earlier this year over management's "extreme" reaction to a workplace gossiping incident, prompting the PSA to file personal grievance proceedings, James said.

James says resignations are continuing.

'People are resigning even now'

After the complaints, WorkSafe alerted Defence in mid-June "concerning the leadership and bullying allegations".

Defence responded: "You also mentioned you had received multiple reports of suicidal thoughts from both complainants and witnessed in others by complainants.

"These further concerns are obviously serious and we recognise and want to support our people, however, so far no complaints have been received by NZDF."

Claims centre on a workplace culture that has been described by ex-workers as "incredibly toxic" since about 2019.

James said that "if anything it has got worse" since the complaints, despite Defence telling VA staff they were taking action.

"People are resigning ... even now, within the last month."

'Unbiased and independent'

Defence asked WorkSafe in July to provide details so it could help, "in particular the employees who are at most risk".

WorkSafe told the complainants to contact a Defence Captain, so they would not have a fear of "retribution".

It is not known if complainants did this.

James said members had gone to WorkSafe because they feared retaliation if they had raised matters direct with the NZDF.

"They've seen others raising concerns and being dealt with inappropriately."

WorkSafe's official advice is that bullying investigations should be done by someone "unbiased and independent".

Asked about this by RNZ, Defence said it and VA had agreed to implement all of WorkSafe's requests.

"If WorkSafe believed that the matter necessitated a more urgent response or that their requests weren't being implemented appropriately, it would have expected WorkSafe to tell it," Defence said by email.

Defence did not respond to whether employee health and safety representatives are supporting staff.

James said he understood the Defence review constituted an investigation of management - but said this should be done independently.

Other government advice is that bullying investigations can be complex and when "there is a risk of a toxic work environment" organisations can opt to bring in an external investigator.

Three months on from the first complaint, WorkSafe says it is still engaged in "initial enquiries".

"This isn't a formal investigation at this stage and Veterans' Affairs has been cooperative," it told RNZ.

'Box ticking'

WorkSafe can investigate bullying, but has been struggling with the scope of the issue.

Documents show that last year, faced with a jump in bullying complaints, it was trying to get up to speed on bullying.

It had realised that its staff were "not adequately trained", and its investigations too "narrow". It was also struggling to assess, or triage, bullying complaints properly.

The PSA says that, in the current case, WorkSafe told the union it would review the bullying policies at VA.

"That is box ticking," James said.

No matter how good the policies looked, they clearly are not being followed, he said.

Defence told RNZ it would review bullying policy, worker engagement, representation and participation at its unit.

James said years of staff problems had culminated in an internal survey that revealed very low morale at Veterans' Affairs about a year ago.

Since then, things had degenerated, he claimed.

"Members have contacted us simply saying that they could not bear it anymore."

Bullying complaints nationwide to WorkSafe leapt from 100 between 2014 and 2017, to 89 in 2018 alone.

VA, with 80 staff and a $76m annual budget, works with 12,000 mostly elderly returned servicepeople and 20 support groups, and helps service 183 cemeteries.

Defence's chief people officer Colonel Helen Cooper said the review would not impact on any of the services provided to veterans.

Veterans' Affairs overhauled its approach after a review in 2018 and law changes last year.

One of its four goals is "generating a sustainable workforce to deliver excellent client service".

WorkSafe in an additional statement said it was not the right agency to support workers who may be suicidal, and instead informed them about health providers who could help.

Its job was to review what an organisation did about bullying, not tell it what to do, WorkSafe said.

It was looking to see if Defence and Veterans' Affairs had the right systems in place, it said.

While it encouraged workers to raise health and safety concerns directly with managers, in this case it had "respected the wishes of those workers involved who have not wanted to raise issues internally".

WorkSafe has in the past year set up an internal mental health work team, and kaimahi hauora health inspectors.

Read the full OIA response:

Where to get help:

Need to Talk? Free call or text 1737 any time to speak to a trained counsellor, for any reason.

Lifeline : 0800 543 354 or text HELP to 4357

Suicide Crisis Helpline: 0508 828 865 / 0508 TAUTOKO (24/7). This is a service for people who may be thinking about suicide, or those who are concerned about family or friends.

Depression Helpline : 0800 111 757 (24/7) or text 4202

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Youthline : 0800 376 633 (24/7) or free text 234 (8am-12am), or email [email protected]

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• Introduction
• Conclusions
• Article Information

The sizes of the circles and overlapping areas are proportional to the number of participants reporting the indicated exposure(s).

eMethods. Supplemental Methods

eTable 1. Results of the Fully Adjusted Model of Past-12-Month Major Depressive Disorder

eTable 2. Results of the Fully Adjusted Model of Past-12-Month Intermittent Explosive Disorder

eTable 3. Results of the Fully Adjusted Model of Past-12-Month Posttraumatic Stress Disorder

eTable 4. Results of the Fully Adjusted Model of Past-12-Month Suicidal Ideation

eTable 5. Results of the Fully Adjusted Model of Past-30-Day Substance Use Disorder

eReferences

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Campbell-Sills L , Sun X , Kessler RC , Ursano RJ , Jain S , Stein MB. Exposure to Bullying or Hazing During Deployment and Mental Health Outcomes Among US Army Soldiers. JAMA Netw Open. 2023;6(1):e2252109. doi:10.1001/jamanetworkopen.2022.52109

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Exposure to Bullying or Hazing During Deployment and Mental Health Outcomes Among US Army Soldiers

• 1 Department of Psychiatry, University of California, San Diego, La Jolla
• 2 Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla
• 3 Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
• 4 Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland
• 5 Veterans Affairs San Diego Healthcare System, San Diego, California

Question   Is being bullied or hazed by fellow unit members during a combat deployment associated with poorer mental health outcomes among US Army soldiers?

Findings   This cohort study analyzed data from 1463 combat-deployed soldiers and found that reports of being bullied or hazed during deployment were significantly associated with major depressive disorder, intermittent explosive disorder, posttraumatic stress disorder, suicidal thoughts, and substance use disorder.

Meaning   Recognition of the associations between bullying or hazing and mental health conditions can inform efforts to prevent and address these problems in combat-deployed service members.

Importance   Workplace bullying is associated with mental disorders and suicidality in civilians, but few studies have examined associations of bullying with these outcomes among military personnel.

Objective   To evaluate associations of being bullied or hazed during deployment with major depressive disorder (MDD), intermittent explosive disorder, posttraumatic stress disorder (PTSD), suicidal ideation, and substance use disorder (SUD).

Design, Setting, and Participants   This cohort study used data from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) New Soldier Study (NSS; April 1, 2011, to November 30, 2012) and wave 1 of the STARRS Longitudinal Study (STARRS-LS1; September 1, 2016, to April 30, 2018). A computerized survey administered at 3 US Army installations (NSS) and a web/telephone survey (STARRS-LS1) were used to collect data. Data were analyzed from October 11, 2021, to October 28, 2022. The STARRS-LS1 recruited a probability sample of active-duty soldiers and veterans who had participated in Army STARRS baseline surveys while on active duty (weighted response rate, 35.6%). Respondents whose baseline was the NSS and who had deployed to a combat theater at least once were eligible for this study.

Exposures   Being bullied or hazed during a combat deployment.

Main Outcomes and Measures   The primary outcomes were MDD, intermittent explosive disorder, PTSD, and suicidal ideation in the 12 months before STARRS-LS1 and SUD in the 30 days before STARRS-LS1, assessed with items from the Composite International Diagnostic Interview Screening Scales, PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition , and Columbia-Suicide Severity Rating Scale. Logistic regression was used to estimate associations of bullying or hazing exposure with the outcomes.

Results   The 1463 participants were predominantly male (weighted percentage [SE], 90.4% [0.9%]) and had a mean (SE) age of 21.1 (0.1) years at baseline. At STARRS-LS1, 188 respondents (weighted percentage [SE], 12.2% [1.1%]) reported bullying or hazing during deployment. Weighted outcome prevalences were 18.7% (1.3%) for MDD, 5.2% (0.9%) for intermittent explosive disorder, 21.8% (1.5%) for PTSD, 14.2% (1.2%) for suicidal ideation, and 8.7% (1.0%) for SUD. In models that adjusted for baseline sociodemographic and clinical characteristics and other potential traumas, exposure to bullying or hazing was significantly associated with MDD (adjusted odds ratio [aOR], 2.92; 95% CI, 1.74-4.88), intermittent explosive disorder (aOR, 2.59; 95% CI, 1.20-5.59), PTSD (aOR, 1.86; 95% CI, 1.23-2.83), suicidal ideation (aOR, 1.91; 95% CI, 1.17-3.13), and SUD (aOR, 2.06; 95% CI, 1.15-3.70).

Conclusions and Relevance   In this cohort study of combat-deployed soldiers, reports of being bullied or hazed during deployment were associated with mental disorders and suicidal thoughts. Recognition of these associations may inform efforts to prevent and address mental health problems among service members.

Workplace bullying encompasses a variety of threatening, humiliating, and disruptive acts that occur in an occupational setting and are intended to cause physical or psychological harm to the person being bullied. 1 The related phenomenon of hazing involves similar behaviors but with the purported aim of initiating the person being hazed into a group. Prospective studies 2 - 7 indicate that workplace bullying is associated with onset of mental health problems in civilians. However, few studies have examined associations between bullying or hazing and mental health outcomes among military personnel.

The available data from military samples suggest links between bullying or hazing exposure and problems such as depression, anger, alcohol misuse, and suicidal thoughts. 8 - 12 However, the extent to which the observed associations reflect influences of concomitant risk factors (eg, preexisting mental health problems or other stressors) is poorly understood. Investigation of whether exposure to bullying or hazing explains unique variance in mental health outcomes of service members could inform efforts to reduce the burden of mental disorders and suicidality in this population.

In support of this aim, the current study examines associations of bullying or hazing with mental health outcomes among combat-deployed soldiers. Deployment is a period characterized by increased stress and diminished access to nonmilitary sources of social support that may protect against adverse outcomes of bullying or hazing. 13 Unit cohesion appears to mitigate the effects of deployment stressors 14 ; however, this buffer may be compromised for soldiers who are targets of malicious behavior perpetrated by fellow unit members. Of importance, whereas stressors such as combat are unavoidable for some deployed soldiers, bullying and hazing can be prevented and/or addressed by leaders (ie, they can be intervention targets). These contextual factors provide additional impetus for examining associations between mental health and exposure to bullying or hazing in a deployment setting.

The analyses described in this report specifically evaluate associations between bullying or hazing during deployment and major depressive disorder (MDD), intermittent explosive disorder, posttraumatic stress disorder (PTSD), suicidal ideation, and substance use disorder (SUD) in wave 1 of the Study to Assess Risk and Resilience in Servicemembers (STARRS) Longitudinal Study (STARRS-LS1). 15 The analyses estimate these associations controlling for sociodemographic and clinical characteristics measured in the baseline New Soldier Study (NSS), 16 as well as other potential traumas experienced by soldiers during the follow-up interval. Given the distinctive aspects of bullying or hazing vis-à-vis other military stressors, the hypothesis of this study was that bullying or hazing during deployment would be independently associated with the mental health outcomes.

STARRS-LS recruited a probability sample of soldiers who had participated in components of Army STARRS 16 while on active duty. The first wave of follow-up data collection (STARRS-LS1) occurred from September 1, 2016, to April 30, 2018, with surveys administered via web or telephone (weighted response rate, 35.6%). Data were analyzed from October 11, 2021, to October 28, 2022. STARRS-LS1 participants provided written informed consent, and the study was approved by the human subjects committees of the collaborating institutions. Other information regarding STARRS-LS1 and the study measures is provided in the eMethods in Supplement 1 and a prior publication. 15 This study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

This study focuses on the subset of the STARRS-LS1 cohort whose baseline was the Army STARRS NSS. 17 The NSS was conducted at 3 US Army installations from April 1, 2011, to November 30, 2012. Consenting soldiers completed a computerized survey before Basic Combat Training that assessed sociodemographic characteristics, lifetime Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition mental disorders, and risk/protective factors. The final NSS sample 18 consisted of 38 507 soldiers, 6216 of whom completed the STARRS-LS1 survey. Of these, 1467 reported ever deploying to a combat theater, making them eligible for this study. Four eligible respondents were excluded due to missing bullying or hazing data, resulting in a sample size of 1463. The weighted mean (SE) interval between NSS and STARRS-LS1 surveys was 5.4 (0.03) years. The eMethods in Supplement 1 contains additional information about the study measures.

The STARRS-LS1 survey evaluated Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition mental disorders with items adapted from the Composite International Diagnostic Interview Screening Scales (CIDI-SC) 19 and PTSD Checklist for DSM-5 (PCL-5). 20 Suicidal ideation was assessed using an expanded self-report version of the Columbia-Suicide Severity Rating Scale (C-SSRS). 21 The outcomes for this study were MDD, intermittent explosive disorder, PTSD, and suicidal ideation in the 12 months before STARRS-LS1 and SUD in the 30 days before STARRS-LS1 (SUD in the past 12 months was not assessed).

The STARRS-LS1 survey queried events that occurred “during any deployment you had in a combat theatre since your last interview.” For the NSS cohort, this timeframe covered all the soldier’s deployments to that point. The item assessing bullying or hazing asked if the respondent had been bullied or hazed by 1 or more members of their unit. Response options on the web survey were 0, 1, 2 to 4, 5 to 9, and 10 or more times, whereas options on the telephone interview were yes or no. For harmonization purposes, all responses to the bullying or hazing item were coded as 0 (0 times/no) or 1 (≥1 time/yes).

The STARRS-LS1 survey also assessed exposure to combat stressors, sexual assault during deployment, physical assault during deployment, and potential traumas that occurred outside deployments. Six trauma exposure variables were derived for logistic regression analysis: a combat exposure score (range, 0-11, with 0 indicating no reported exposure to the combat experiences assessed in the survey and 11 indicating reported exposure to all combat experiences assessed in the survey) and binary variables capturing physical assault (while deployed or not), sexual assault (while deployed or not), other life-threatening events (outside deployment), witnessing or being repeatedly exposed to details of traumas that happened to other people (outside deployment), and serious injury or death of a loved one (outside deployment). Two additional binary variables were derived for descriptive purposes. High combat exposure identified respondents scoring in the upper quartile of the combat exposure score distribution (combat exposure score >5). Noncombat trauma exposure identified respondents reporting any physical assault, any sexual assault, other life-threatening events (outside deployment), witnessing or being exposed to details of trauma that happened to others (outside deployment), and serious injury or death of a loved one (outside deployment).

The NSS survey evaluated lifetime DSM-IV mental disorders using items adapted from the CIDI-SC 19 and the PTSD Checklist–Civilian Version (PCL-C) 22 and lifetime suicidal ideation using an expanded self-report version of the C-SSRS. 21 To account for variance in mental health outcomes related to sociodemographic and service characteristics, all multivariable models included age, sex, race and ethnicity, educational level (coded General Educational Development or equivalent, high school diploma, or college degree), and service component (regular US Army, US Army National Guard, or US Army Reserve). These data were collected via self-report in the NSS survey; for race and ethnicity, respondents chose 1 or more options from predetermined categories. Given low endorsement of certain categories, race and ethnicity responses were recoded as Hispanic, non-Hispanic Black, non-Hispanic White, or other (includes American Indian or Alaska Native, Asian, Native Hawaiian or other Pacific Islander, and any other race).

All statistical analyses were conducted in R, version 3.6.1 (R Foundation for Statistical Computing). 23 Weights developed for the NSS and STARRS-LS1 surveys were applied to adjust for nonresponse and for differences between respondents and the population of soldiers they were intended to represent (ie, poststratification weights). Details about the weights are provided elsewhere. 15 , 24 Differences between respondents who reported vs denied being bullied or hazed during deployment were evaluated using design-based Wald tests and 2-sided, unpaired t tests for categorical and continuous variables, respectively. Weights-adjusted logistic regression was used to estimate the associations of exposure to bullying or hazing during deployment with mental health outcomes at STARRS-LS1. Subsequent logistic regression models estimated these associations adjusting for sociodemographic and service characteristics and lifetime history of the outcome at baseline (note that the model of suicidal ideation also adjusted for lifetime MDD at baseline). Final models added adjustment for other potential traumas during the follow-up interval (n = 1431 for these models because 32 respondents were missing data for 1 or more trauma variables). Two-tailed P  < .05 was considered statistically significant.

The sample comprised 1463 soldiers, of whom 1269 were male (weighted percentage [SE], 90.4% [0.9%]) and 194 were female (weighted percentage [SE], 9.6% [0.9%]), with a mean (SE) age of 21.1 (0.1) years. A total of 222 respondents were Hispanic (weighted percentage [SE], 18.3% [1.3%]), 185 were Black (weighted percentage [SE], 16.2% [1.2%]), 945 were White (weighted percentage [SE], 58.1% [1.7%]), and 111 were of other race or ethnicity (weighted percentage [SE], 7.4% [0.9%]). A majority of respondents had enlisted in the regular Army (n = 1104; weighted percentage [SE], 80.4% [1.6%]). Table 1 lists the other characteristics of the sample and of the 188 respondents (weighted percentage [SE], 12.2% [1.1%]) who reported that they had been bullied or hazed during a combat deployment. Respondents who reported bullying or hazing during deployment were younger, disproportionately female, more likely to have reported lifetime PTSD and suicidal ideation at baseline, and more likely to have reported several other deployment and nondeployment stressors ( Table 1 ). The Figure depicts the co-occurrence of bullying or hazing during deployment with other types of trauma exposure during the follow-up interval.

At the STARRS-LS1 follow-up, weighted percentages (SEs) of 42.1% (1.6%) of respondents were on active duty in the regular US Army, 4.7% (0.7%) were activated guard members or reservists, 21.2% (1.5%) were deactivated guard members or reservists, 27.9% (1.3%) were separated, and 4.1% (0.7%) were retired. Outcome prevalences were 18.7% (1.3%) for MDD, 5.2% (0.9%) for intermittent explosive disorder, 21.8% (1.5%) for PTSD, 14.2% (1.2%) for suicidal ideation, and 8.7% (1.0%) for SUD. Table 2 summarizes the results of logistic regression models that estimated associations between exposure to bullying or hazing during deployment and the outcomes. In unadjusted models, bullying or hazing was associated with significantly increased risk of all the mental health outcomes (OR, 3.60 [95% CI, 2.33-5.57] for MDD in the past 12 months; OR, 3.32 [95% CI, 1.40-7.84] for intermittent explosive disorder in the past 12 months; OR, 2.99 [95% CI, 2.04-4.38] for PTSD in the past 12 months; OR, 2.74 [95% CI, 1.83-4.09] for suicidal ideation in the past 12 months; and OR, 2.52 [95% CI, 1.30-4.88] for SUD in the past 30 days) ( Table 2 ). Some attenuation of these associations occurred when controls were added for baseline sociodemographic and clinical characteristics and for other potential traumas that had occurred during the follow-up interval. However, as indicated in Table 2 , reports of bullying or hazing during deployment remained significantly associated with all outcomes, even in the fully adjusted models. Detailed results of the fully adjusted models are provided in eTables 1 to 5 in Supplement 1 .

In this cohort study of combat-deployed soldiers, reports of having been bullied or hazed by fellow unit members during deployment were associated with mental disorders and suicidal ideation at the STARRS-LS1 follow-up. These associations partly reflected that bullying or hazing and other potential traumas (eg, combat exposure and sexual assault) were highly intercorrelated and explained common variance in mental health outcomes. Nevertheless, bullying or hazing during deployment displayed independent associations with all study outcomes, including MDD, intermittent explosive disorder, PTSD, suicidal ideation, and SUD. Although causality cannot be assumed, these results raise the possibility that US Army policies and programs (eg, leader trainings) that aim to eradicate bullying and hazing may help reduce mental disorders and suicidality among soldiers.

Bullying or hazing displayed a particularly strong association with MDD in the past 12 months at the STARRS-LS1 follow-up. Interpersonal problems are a common antecedent of MDD, 25 and aspects of bullying or hazing (eg, social rejection, humiliation) might trigger or exacerbate depressed mood in vulnerable individuals. 26 , 27 Other data suggest that depressed mood may at times elicit social rejection or relationship stress, 28 potentially fostering a vicious cycle in which interpersonal problems and depression worsen over time. Although our models controlled for lifetime MDD at baseline, depression may have predated the bullying or hazing in some cases (eg, subthreshold MDD may have been present at baseline; onset of a depressive disorder could have occurred during the interval between baseline and exposure to bullying or hazing during deployment). Thus, the association between bullying or hazing during deployment and MDD is likely attributable to diverse and potentially bidirectional mechanisms.

Bullying or hazing during deployment also exhibited a strong association with intermittent explosive disorder in the past 12 months, a condition characterized by aggressive outbursts. This finding is broadly consistent with cross-national epidemiologic data showing elevated rates of intermittent explosive disorder among individuals exposed to interpersonal violence. 29 As with MDD, various mechanisms could underlie the association between bullying or hazing and intermittent explosive disorder. 8 , 9 Perceived injustice is a key anger trigger; as such, it is plausible that the experience or subsequent recollection of bullying or hazing could lead to increased anger or lower the threshold for aggressive outbursts. Conversely, preexisting anger difficulties (which may not have been fully captured in our models) could contribute to aggressive exchanges with unit members, which in turn could affect the likelihood of being a target of bullying or hazing.

Exposure to bullying or hazing also explained unique variance in PTSD, suicidal ideation, and SUD. Of note, the survey did not ascertain whether PTSD symptoms were triggered by bullying or hazing. Indeed, many forms of bullying or hazing do not involve actual or threatened physical injury or sexual violence (ie, they would not meet criterion A for DSM-5 diagnosis of PTSD). Nevertheless, contextual factors may exacerbate or mitigate impacts of traumatic events. Perceiving an atmosphere of threat within one’s unit could increase a soldier’s vulnerability to PTSD following other traumas, much like perceiving support from fellow unit members appears to protect against PTSD in combat-exposed soldiers. 14 The association of bullying or hazing with suicidal ideation likely relates to the elevated rate of MDD in exposed soldiers. Some evidence also suggests that perceptions of being a burden to other people may contribute to associations between bullying exposure and suicidality. 12 The observation of elevated risk of SUD among combat-deployed soldiers exposed to bullying or hazing converges with results showing greater alcohol misuse among South Korean military personnel exposed to hazing 9 and is consistent with evidence that substance use may be used as a way of coping with negative emotions that can result from workplace exposure to bullying or hazing. 30

Approximately 1 in 8 soldiers (12.2%) reported that they had been bullied or hazed while deployed, suggesting the eradication of these behaviors could impact large numbers of service members during a critical time. Although investigations of unit-level influences on bullying or hazing are scarce, a study 31 of Norwegian naval personnel found that departments receiving higher scores on a measure of fair leadership had lower proportions of personnel reporting that they had experienced bullying or witnessed a fellow unit member being bullied. Fair leadership included behaviors such as superiors treating members fairly and equally or distributing duties in a fair and equitable manner. It may be worthwhile to evaluate whether training focused on cultivating fair leadership practices affect incidence of bullying or hazing within military units.

Several sociodemographic and clinical correlates of bullying or hazing observed in this combat-deployed population have been reported in prior studies. 31 - 35 For example, civilian studies have found workplace bullying to be more commonly reported by women 32 , 33 and those with preexisting PTSD, 34 implying that these characteristics are associated with reports of being bullied across different occupational settings, not just in the context of military deployment. Another study 31 found that younger military personnel were more likely to have experienced or witnessed bullying in their unit, converging with our results indicating a higher rate of being bullied among younger soldiers. Finally, in this study, bullying or hazing was associated with more combat exposure, which may indicate that these behaviors are more common in units with more direct combat roles. A study 35 of female UK military veterans similarly found that military adversity, which included emotional bullying, was more frequently reported by women who had served in combat or combat support roles. To help target prevention efforts, future studies should evaluate whether bullying and hazing tend to cluster within military units and whether certain unit characteristics (eg, combat role, cohesion, and leadership) are associated with incidence of bullying or hazing.

Finally, soldiers who reported being bullied or hazed were also more likely to report physical and sexual assault (including during deployment). The survey did not clarify whether those traumas occurred separately or as part of the bullying or hazing. 36 The survey also did not assess other forms of military sexual trauma (eg, sexual harassment) that may co-occur or have unclear boundaries with bullying or hazing. Future studies should gather more detailed information to elucidate the unique vulnerabilities of individuals who experience distinct types of interpersonal trauma (eg, physical aggression or verbal abuse) or bullying or hazing that involves sexually assaultive or harassing behavior. The co-occurrence of bullying or hazing with combat exposure and noncombat trauma is consistent with evidence that stressors may cluster together and compound risk for some individuals. 37 , 38

This study has some limitations. First, causal inferences should not be made, because mental health conditions observed at follow-up could have predated the bullying or hazing exposure and unmeasured variables might have contributed to the observed associations between bullying or hazing exposure and the outcomes. We mitigated these issues by controlling for baseline characteristics (including lifetime history of mental health conditions) and other trauma exposure; however, these issues remain limitations of the study. Second, retrospective reports of life events and mental health symptoms may be affected by inaccurate recall, hesitancy to report stigmatized experiences, and reporting biases. Possible effects include underestimation of the prevalence of bullying or hazing or other abuse due to poor recall or underreporting of stigmatized experiences and potential inflation of associations between bullying or hazing and mental health problems due to mood-congruent reporting biases (eg, negative emotions could facilitate recall of adverse events, whereas positive emotions could foster minimization of bullying or hazing experiences). Third, the survey included only 1 item that assessed bullying or hazing exposure. Definitions of these exposures were not provided, and participants’ self-reports were not validated through other modalities. Respondents may have reported events that would not meet accepted definitions of bullying or hazing or failed to report bullying or hazing because they were unsure if their experiences qualified as such. Fourth, the nature of bullying or hazing was not assessed (including whether it involved sexual assault or harassment), and its frequency was not considered because telephone participants were only administered a yes or no item about bullying or hazing. Therefore, we were unable to evaluate how the nature or frequency of the bullying or hazing affected risk of mental health problems. Moreover, although bullying and hazing are similar phenomena, there may be differences in their psychological impact or in risk factors for being a target of bullying vs hazing. Then again, discriminating between bullying and hazing is often not possible because the intent of the malicious behavior and how the target interprets it may diverge (or be ambiguous). 11 Finally, some individuals may have experienced mental health problems related to bullying or hazing that were not captured in the STARRS-LS1 survey (eg, if the problems occurred during or shortly after deployment and resolved >1 year before the follow-up survey).

In this cohort study of combat-deployed US Army soldiers, reports of being bullied or hazed during deployment were associated with mental disorders and suicidal ideation at follow-up. These associations remained significant after adjusting for baseline characteristics and other potential traumas during the follow-up period. Unlike combat exposure, bullying or hazing is an avoidable event that appears to affect a substantial proportion of deployed soldiers (approximately 1 in 8 in this sample). Continued vigilance and implementation of prevention strategies 39 is warranted and may help reduce incidence of mental health problems among soldiers. Furthermore, fostering awareness and effective responses among unit leaders is important when bullying or hazing occurs, given evidence that support from leadership may buffer some effects of peer abuse. 40 Finally, more research is needed to replicate these findings and clarify how the nature, frequency, and timing of bullying or hazing relate to mental health risk.

Accepted for Publication: December 1, 2022.

Published: January 24, 2023. doi:10.1001/jamanetworkopen.2022.52109

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Campbell-Sills L et al. JAMA Network Open .

Corresponding Author: Laura Campbell-Sills, PhD, Department of Psychiatry, University of California, San Diego, 9500 Gilman Dr, Mail Code 0855, La Jolla, CA 92093-0855 ( [email protected] ).

Author Contributions: Dr Jain and Ms Sun had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Campbell-Sills, Stein.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Campbell-Sills, Jain, Stein.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Sun, Jain.

Obtained funding: Kessler, Ursano.

Administrative, technical, or material support: Campbell-Sills, Ursano.

Supervision: Stein.

Conflict of Interest Disclosures: Dr Kessler reported receiving consultant fees from Cambridge Health Alliance, Canandaigua Veterans Affairs Medical Center, Holmusk, Partners Healthcare Inc, Rallypoint Networks Inc, and Sage Therapeutics and having stock options in Cerebral Inc, Mirah, PYM, and Roga Sciences outside the submitted work. Dr Stein reported receiving personal fees from Acadia Pharmaceuticals, Atai Life Sciences, Aptinyx, BigHealth, Bionomics, BioXcel Therapeutics, Boehringer Ingelheim, Clexio, Eisai, EmpowerPharm, Engrail Therapeutics, Janssen, Jazz Pharmaceuticals, NeuroTrauma Sciences, PureTech Health, Sumitomo Pharma, and Roche/Genentech and stock options in Oxeia Biopharmaceuticals and EpiVario outside the submitted work. In the past 3 years, Dr Stein has been paid for his editorial work on Depression and Anxiety (editor in chief), Biological Psychiatry (deputy editor), and UpToDate (co–editor in chief for psychiatry). He is on the scientific advisory board for the Brain and Behavior Research Foundation and the Anxiety and Depression Association of America. No other disclosures were reported.

Funding/Support: The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) was sponsored by the US Department of the Army and funded under cooperative agreement U01MH087981 with the US Department of Health and Human Services, National Institute of Health, National Institute of Mental Health. Subsequently, the STARRS Longitudinal Study was sponsored and funded by grants HU00011520004 and HU0001202003 from the US Department of Defense. The grants were administered by the Henry M. Jackson Foundation for the Advancement of Military Medicine Inc.

Role of the Funder/Sponsor: As a cooperative agreement, scientists employed by the National Institute of Health and US Army as liaisons and consultants collaborated to develop the Army STARRS study protocol and data collection instruments and to supervise data collection. The funders had no further role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The contents are solely the responsibility of the authors and do not necessarily represent the views of the US Department of Health and Human Services, National Institute of Health, US Army, US Department of Defense, or Henry M. Jackson Foundation for the Advancement of Military Medicine Inc.

Data Sharing Statement: See Supplement 2 .

Additional Information: The Army STARRS team consists of the following: coprincipal investigators: Robert J. Ursano, MD (Uniformed Services University), and Murray B. Stein, MD, MPH (University of California, San Diego and Veterans Affairs San Diego Healthcare System); site principal investigators: James Wagner, PhD (University of Michigan), and Ronald C. Kessler, PhD (Harvard Medical School); US Army scientific consultant/liaison: Kenneth Cox, MD, MPH (Office of the Assistant Secretary of the Army [Manpower and Reserve Affairs]); and other team members: Pablo A. Aliaga, MA (Uniformed Services University), David M. Benedek, MD (Uniformed Services University), Laura Campbell-Sills, PhD (University of California, San Diego), Carol S. Fullerton, PhD (Uniformed Services University), Nancy Gebler, MA (University of Michigan), Meredith House, BA (University of Michigan), Paul E. Hurwitz, MPH (Uniformed Services University), Sonia Jain, PhD (University of California, San Diego), Tzu-Cheg Kao, PhD (Uniformed Services University); Lisa Lewandowski-Romps, PhD (University of Michigan), Alex Luedtke, PhD (University of Washington and Fred Hutchinson Cancer Research Center), Holly Herberman Mash, PhD (Uniformed Services University), James A. Naifeh, PhD (Uniformed Services University), Matthew K. Nock, PhD (Harvard University), Nur Hani Zainal, PhD (Harvard Medical School), Nancy A. Sampson, BA (Harvard Medical School), and Alan M. Zaslavsky, PhD (Harvard Medical School).

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Veterans Affairs administration ignored complaints of harassment and bullying, federal watchdog says

The Department of Veterans Affairs failed to seriously investigate harassment allegations by four women against the chief of anesthesiology at Vermont’s White River Junction Veterans Affairs Medical Center, the head of a federal watchdog agency concluded Thursday.

In a sharply critical letter to President Biden, Henry Kerner, the head of the US Office of Special Counsel, said the VA showed “a willingness to resolve issues in favor of the agency, despite significant evidence to the contrary.”

VA investigators rejected nearly all of the women’s allegations and refused to review them further “to resolve unanswered and potentially troubling questions” even after the Office of Special Counsel, which investigates whistle-blower complaints by federal employees, instructed them to, Kerner found.

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In 2018, a doctor and three other operating room employees filed whistle-blower complaints against Dr. Fima Lenkovsky, then the chief of the hospital’s anesthesiology department.

They accused him of sleeping on the job, bullying and harassing women, and striking a nurse during an operation in June 2018.

One of the whistle-blowers, anesthesiologist Jennifer Keller, was fired, allegedly for endangering patient safety by leaving a medical student unattended during surgery. However, the doctor and the other women asserted that she was fired for speaking out against Lenkovsky, who was suspended for 30 days and then allowed to retire. Until then, Keller had an unblemished record, her lawyer said.

Kerner wrote that the VA discounted “a concerning and significant pattern of violent physical behavior by this individual (Lenkovsky) directed toward female staff.”

When the Globe reported on the allegations in July 2019 , a VA spokesman dismissed the allegation that Lenkovsky had intentionally struck Christine Murphy, the hospital’s chief nurse anesthetist. The spokesman called the charge “blatantly dishonest” and “disrespectful to actual assault victims, which Murphy is clearly not.” He claimed the contact was accidental.

Kerner found the spokesman’s comments especially troubling.

“The agency seems to disregard a concerning and significant pattern of violent physical behavior by this individual directed toward female staff,” said Kerner, who called the press statement “an appalling attack on a VA employee who was struck by a supervisor while appropriately discharging her duties.”

VA spokesman Alan Greilsamer issued a statement saying: “This matter was investigated by VA’s Office of the Medical Inspector and former Secretary (Robert) Wilkie signed the reports to the Office of Special Counsel containing the agency’s findings. We see no reason to disturb those findings now, but we fully support the rights of all VA whistleblowers to raise matters of concern so they can be reviewed and remedied when appropriate.”

On Thursday, Keller said she and the other women were “very pleased that the Office of Special Counsel recognized that injustice was done here.”

“There are wrongs that still need to be righted,” she said. “The culture for women and those not in power remains hostile. Leadership is still entrenched and promotes a culture of self-affirmation, accusing others without basis while ignoring its own failures. Until the issue of competent leadership is addressed directly, veterans won’t receive the care they need.”

In an interview, Lenkovsky said a lengthy investigation concluded he had done nothing wrong.

“It’s such a long story,” he said. “I’ve been retired for more than three years. An independent panel cleared me of all wrongdoing. Why should it be reopened again? The doctor who complained should never work with patients.”

The women first filed complaints with the Office of Special Counsel, an independent federal agency, which found the complaints had merit and ordered the VA’s Office of Medical Inspector to conduct a deeper investigation. Thursday’s letter represented the Special Counsel’s response to the VA’s findings.

The agency has no authority to order changes and can only send its findings to the president and Congress. That allows wrongdoing, individual and systemic, to go unpunished, said Andrea Amodeo-Vickery, one of the lawyers who represented the women in the Vermont case.

“This is the fourth case I have worked on involving a VA medical center where doctors have complained about inadequate patient care, abuse of patients, and abuse of personnel,” she said. “The Office of Special Counsel writes to the president and Congress complaining about the inappropriateness of another section of the VA being tasked to investigate itself.

“It doesn’t work and so the abuse goes on unchecked by either Congress or the president. All the good guys get fired,” she said.

Phillipa Lilienthal, a lawyer who also represents the whistle-blowers, said Kerner’s letter “aptly identified some of the troubling issues in this case. There were significant institutional disclosures by multiple employees regarding a pattern of abusive behavior by Dr. Lenkovsky, in particular behavior directed at subordinate female employees. Yet the VA ignored the evidence and determined there were no concerns.”

Most of the women are still working at the Vermont facility, as are some of the officials “who tacitly or vocally” approved Lenkovsky’s behavior, she said.

“The whistle-blowers also urge the VA to do more to ensure that the rights of employees are protected, because employees who are not protected from abuse put veterans’ safety at risk,” she said.

The VA did substantiate one allegation — that a patient was harmed while being intubated. Though the whistle-blowers blamed Lenkovsky, he blamed another inexperienced doctor and the VA agreed, contradicting eyewitness testimony, Kerner found.

Andrea Estes can be reached at [email protected] .

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Federal watchdog finds VA ignored bullying complaints

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A federal watchdog agency has found that Vermont’s Department of Veterans Affairs Hospital failed to properly investigate allegations from several employees about bullying and other abuses by another doctor.

In a letter to President Joe Biden Thursday, the Office of Special Counsel’s Henry Kerner acknowledged that the VA was unable to substantiate the allegations of serious misconduct against Fima Lenkovsky, the former chief of the hospital’s anesthesiology department, who has since retired. But Kerner said its conclusions “appears to ignore both the details of a prior incident and the sworn testimony of the whistleblowers that included information regarding several confrontational incidents involving the doctor.”

“The reports evince a willingness to resolve issues in favor of the agency, despite significant evidence to the contrary and a reluctance to conduct further review to resolve unanswered and potentially troubling questions,” Kerner said in his letter. “For these reasons, I have determined that the agency’s findings do not appear reasonable.”

Lawyers representing the four employees, who are all women, welcomed the watchdog agency’s finding.

“The VA’s continued willingness to resolve issues in favor of the agency, despite significant evidence to the contrary, shows that it was incapable of policing itself,” Phillipa Lilienthal and Andrea Amodeo-Vickery said in a joint statement. “Our clients, the female health care providers who served Veterans faithfully for decades, should have been protected when they reported verbal and physical abuse and inappropriate behavior that caused injury to patients.”

In a response to the letter Friday, the VA said the matter was investigated by the VA’s Office of the Medical Inspector.

“We see no reason to disturb those findings now, but we fully support the rights of all VA whistleblowers to raise matters of concern so they can be reviewed and remedied,” Alan Greilsamer, the VA’s director of media relations, said in a statement.

A phone number could not be found for Lenkovsky, but he told The Boston Globe Thursday that an independent panel had cleared him of wrongdoing.

One of the four employees, Dr. Jennifer Keller, was fired in 2018 from her job at the White River Junction VA hospital after allegedly leaving an operating room during two surgical procedures, putting patient lives at risk.

Keller and other female employees claim her firing came in reprisal for speaking out against Lenkovsky for allegedly bullying and harassing female employees, including reporting an alleged assault against a nurse during an operation in June 2018, when he allegedly hit her arm during a surgery.

The VA denies the allegations that it retaliated against Keller.

Two weeks after the alleged assault, Keller and three nurses, including the nurse who said Lenkovsky hit her, met with the hospital’s acting director, Dr. Brett Rusch. Following the meeting with Rusch, Lenkovsky was suspended during a five-week internal investigation. He returned to work in August and retired in December.

VA officials dismissed the assault allegation as “blatantly dishonest,” prompting Kerner to write in his letter to Biden Thursday that its response was “an appalling attack on a VA employee who was struck by a supervisor while appropriately discharging her duties.”

The Office of Special Counsel, which is an independent federal investigative agency, is still investigating Keller’s claim of retaliation.

In a joint statement, Vermont’s congressional delegation, Democratic U.S. Sen. Patrick Leahy and U.S. Rep. Peter Welch and independent U.S. Sen. Bernie Sanders, came to the defense of the whistleblowers.

“When someone sees something wrong, they need to have the confidence that speaking up will lead to a good faith investigation and positive change,” they said.

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Hazing, Workplace Bullying and your VA Mental Health Claim

Hill & Ponton P.A. Updated: February 24, 2015

Many veterans will tell you about the bond of brotherhood between those they served with, about how close men and women become during times of danger. However, many other veterans tell a different story-a story of shame, anger, and humiliation. Hazing and bullying are common in all branches of the military, and these events can be extremely traumatic for the victim.

When many people think of PTSD , they think of very traumatic experiences related to exposure to actual or threatened death, serious injury or sexual violation. In fact, both the VA and the Diagnostic and Statistical Manual of Mental Disorders (the “bible” of mental illness) specifically state this in their diagnostic criteria. PTSD is the probably the only disorder in the DSM that specifically limits the root cause of the disorder so specifically. However, actual research suggests that this limitation is not very absolute.

In the 1980’s, a doctor named Heinz Leymann decided to research this topic. He labelled the behavior of workplace bullies as “mobbing”- the behavior wild animals display when grouping together to attack a single target. Victims of bullying will certainly relate to this metaphor.

Leymann found that victims of workplace bullying had several health outcomes that were different than those who had not been victims of workplace bullying. Twenty percent of victims committed suicide or developed severe health problems. In his home country of Sweden, he posited that one out of every six suicides in Sweden could be traced back to workplace bullying!

Studies by the The Workplace Bullying & Trauma Institute have found that 76% of victims of workplace bullying experience severe anxiety, 47% experienced PTSD symptoms, 39% experienced clinical depression, and 32% had regular panic attacks .

The VA may deny your claim for PTSD as the result of bullying or hazing while in service, and it seems like you have two options:

• Demonstrate that you were in fear for your life, in fear of serious injury, or in fear of sexual assault.
• Although you may have PTSD, base your claim on your anxiety and depressive symptoms, as anxiety and depression do not have such restrictive criteria.

The trauma of workplace bullying is not a single, quick incident like an IED or a car accident. This trauma is experienced for weeks, months, even years, and it builds and builds until the victim breaks. The effects can last for years, possibly even for the rest of the victim’s life. This can have serious repercussions on future employment, and even social relationships.

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Addressing Suicide in the Veteran Population: Engaging a Public Health Approach

Suicide is a national public health issue in America, and it disproportionately affects those who are serving or who have served in the United States military. The US Department of Veterans Affairs (VA) has made suicide prevention its number one clinical priority. VA is committed to prevent suicide among the entire population of those who have served our country in the military, regardless of whether they make use of any VA services or benefits. Suicide can be prevented through the application of a public health strategy embracing partners at all levels. Following a national strategy, VA has embarked on an effort involving the application of a public health strategy combining both clinically-based and community-focused interventions. This paper describes several examples of these efforts and steps forward.

Introduction

In 2017, 6,139 veterans died by suicide ( 1 ). These veterans were among the over 45,000 Americans who died by suicide during that same year. Suicide is not caused by any one factor, nor can suicide be prevented by application of any one strategy ( 2 , 3 ). While mental health concerns comprise particular risk factors for suicide, larger societal issues also serve as additional unique risk factors for suicide (e.g., homelessness, financial concerns, relationship distress, unemployment, increasing alcohol sales, and increasing sales of and access to firearms). Our national strategies must not only include clinically-based intervention strategies, but also proactive community-based prevention efforts to also address these broader factors. In 2018, VA published a national strategy for preventing Veteran suicide ( 4 ) followed in 2019 by the publication of the revised VA-DoD Clinical Practice Guideline on the Assessment and Management of Patients at Risk for Suicide ( 5 ). These documents provide overarching guidance for the vision and implementation of VA's national suicide prevention initiative.

What we Know From the Data

Since 2014, VA has published an annual report on suicide death data among veterans. The primary purpose of veteran suicide data reporting is to provide critical information to move suicide prevention efforts forward. The VA creates state data sheets as a companion to the national report to prompt local/ regional action ( 6 ). The annual report is based upon a close collaboration with the Department of Defense (DoD) and the Centers for Disease Control and Prevention (CDC). VA and DoD partners complete searches of the National Center for Health Statistics' National Death Index (NDI), the national gold standard of all individuals who have died to identify all individuals who are veterans, which is compiled annually by the CDC based-upon national suicide mortality data reported to the CDC by each state and US territory. NDI data is typically released 11 months after the end of a calendar year and then followed by this extensive detailed review for veterans, which takes significant time to ensure information accuracy. For example, the 2019 National Suicide Prevention Annual Report was published in September 2019, and it included the suicide death data for Veterans between 2005 and 2017 with the reporting period ending on December 31, 2017 ( 1 ).

The report contains information on counts, measures of central tendency, and rates broken down by age, gender, means of death, and a few additional key variables. In 2005, an average of 87 American adults (including an average of 16 veterans) died by suicide each day. In 2017, an average of 124 Americans died by suicide each day (including an average of 17 veterans). However, given the decline in the veteran population during that time period, the suicide rate for veterans in 2017 was 1.5 times higher than the rate for non-veteran adults (2.2 times higher among female veterans than non-veteran women, and 1.3 times higher among male veterans than non-veteran males). The highest rate of suicide among veterans is among male veterans between the ages of 18 and 34, but the highest number of suicides among veterans is among male veterans age 55 and older. Nearly 70% of veteran suicide deaths (69.4%) resulted from a firearm injury which is higher than among non-veteran adult suicide deaths (48.1%).

Foundational Components of Va's Suicide Prevention Initiative: The National Strategy, tHE VA/DoD Clinical Practice Guideline, and Research

National Strategy for Preventing Veteran Suicide ( 4 ) provides a framework for identifying priorities, organizing efforts, and leading a national effort to prevent veteran suicide over the next decade. It aligns with the 2012 National Strategy for Suicide Prevention and the strategy published by the Department of Defense. The National Strategy contains four strategic directions, 14 goals, and 43 specific objectives, all framed within a public health approach. The national strategy is built upon the National Academy of Medicine model of having actions focused on the entire population (Universal), those known to be at higher risk (Selective), and those known to be at highest risk (Indicated). The national strategy leverages the systems within which veterans typically live—families, communities, healthcare systems, workplaces, schools, faith-based and other social groups—to ensure all veterans are reached, both inside and outside of the VA system.

In 2013, the VA and DoD published the first clinical practice guideline (CPG) for the assessment and management of patients at risk for suicide. A revised and updated CPG, the VA/DoD Clinical Practice Guideline for the Assessment and Management of Patients at Risk for Suicide, was published in 2019 and is based upon a thorough review of the existing literature at the time of publication ( 5 ). The CPG is intended to guide clinical decision-making at critical points in the identification and management of suicidal behavior. The CPG identifies essential features and potential actions for both those at acute risk and at chronic risk. The CPG contains five recommendations on screening and evaluation, including three that VA currently uses as part of its comprehensive suicide risk screening and evaluation program. It also contains 12 recommendations on risk management and treatment, including several items that VA currently implements at its health care facilities.

Va's Public Health Approach

To accomplish VA's goal of reducing suicide among all 20 million U.S. Veterans, a comprehensive public health approach that blends clinically-based interventions and community-based prevention strategies is needed (See Figure 1 , National, State, Community Program Coordination). VA is currently deploying both strategies, with high level examples described below, to ensure the fullest implementation of the public health approach to suicide prevention across the nation.

National, state, community program coordination.

Examples of Va's Clinically-Based Interventions

Promoting evidence-based clinical strategies are a key component to suicide prevention. Clinically-based strategies rely upon a foundational level of staffing to ensure success. Mental health staff enhancements have been associated with decreases in suicide rates among VHA patients in regions where the increases in mental health outpatient staffing were greatest ( 7 ). In order to promote maximum success of clinically-based interventions for suicide prevention in alignment with the evidence-base, VA is striving to reach recommended staffing levels. This includes a minimum outpatient mental health staffing ratio of 7.72 outpatient mental health full time employee equivalent (FTE) staff to 1,000 veterans in outpatient mental health and a national minimum benchmark for suicide prevention staffing at 0.1 suicide prevention coordinators/case manager FTEE per 1,000 veterans enrolled at a facility. Below we outline a few examples of clinically-based interventions deployed nationally in VA as part of the strategic plan for suicide prevention.

Universal Screening

Identifying veterans at risk for suicide prior to a time of crisis is a critical factor in the deployment of VA's national strategy. The implementation of universal screening for suicide has a strong evidence-base ( 5 ). In 2018, VA launched the largest standardized suicide risk screening and assessment process in the country, known as the Suicide Risk Identification Strategy (Suicide Risk ID) which includes a first and second level screens followed by a comprehensive suicide risk evaluation as indicated. The population-based mental health screening process is implemented for those with unrecognized risk (universal), for those who may be at risk (selected), and for those at elevated risk (indicated). When initial screening is positive, veterans are provided with a comprehensive suicide risk evaluation. For veterans presenting to other VHA services VA has setting specific guidance for screening and assessment. Between October 1, 2018, and March 2, 2020, 4,533,105 veterans have been screened for suicide across the VHA in all ambulatory settings. Veterans identified at risk through this process are then connected with services to get them the care they need when they need it.

Safety Planning in the Emergency Department

One advantage of working in a large health care system is the ability to deploy innovation at a rapid pace. One such example is the deployment of Safety Planning in Emergency Departments (SPED). National VA leaders were inspired about initial research findings on safety planning and follow-up caring contacts for those seen in emergency department settings ( 8 ). Through implementation of this program, Stanley et al. ( 8 ) found a reduction in suicidal behaviors by almost half (45%) in the 6 months following emergency department visits. VA quickly implemented across the entire VA health care system and SPED was born. When a veteran presents to the emergency department or an urgent care center and is assessed as being at risk of suicide, but still safe enough to be discharged home, VA deploys a suicide safety planning intervention, including lethal means safety counseling, while the person is still in the emergency department or urgent care center. After discharge, the individual veteran is then personally contacted through regular outreach calls to facilitate engagement in outpatient mental health care. Ongoing calls are made until the Veteran is engaged in mental health care. Currently SPED is now being rolled out across all 140 health care systems.

Recovery Engagement and Coordination for Health—Veterans Enhanced Treatment (REACH-VET)

In collaboration with the National Institute of Mental Health, VA developed REACH-VET, a clinical program based upon VA's electronic health record system using predictive analytics to identify veterans at the highest statistical risk for suicide in order to engage outreach and prevention efforts ( 9 , 10 ). Monthly, local points of contact receive list of veterans deemed to be at highest risk for suicide. Clinical providers then provide personal outreach to each individual veteran to ensure all needed care is provided and treatment plans are reviewed ( 11 ). Initial validation studies highlight how this approach identifies veterans with 30–60 times higher rate for suicide, providing a potential mechanism for earlier intervention prior to a time of crisis. Full program evaluation efforts are underway to continue to study outcomes from this national rollout. Progress is tracked monthly and a technical assistance is provided to facilities facing challenges in implementation.

Same Day Access

Connecting veterans to care the same day as services is needed is a critical component of suicide prevention. As part of the My VA Access Initiative, VA established same day mental health and primary care services across the nation in 2017. The My VA Access Initiative also included a larger emphasis on expanded implementation of Primary Care Mental Health Integration (PCMHI) which is one method of providing same day access to mental health services as part of routine primary care, reducing stigma, and increasing timeliness of service delivery. PCMHI has been shown to reduce wait times for mental health services, increase odds of attending future appointments, and lower no-show rates for appointments ( 12 – 15 ). It also provides an opportunity to deliver mental health services to those who may otherwise not seek them and to identify, prevent, and treat mental health conditions at the earliest opportunity. This is an important ingredient in suicide prevention because research has shown that 45% of individuals ( 16 ) who die by suicide have contact with a primary care provider (PCP) in the month prior to their death.

Veterans Crisis Line

In addition to providing same day access to services at VA facilities, the Veterans and Military Crisis Line (VMCL) connects Veterans in crisis with qualified, caring VA responders through a confidential toll-free hotline, online chat, or text 24 h/7days/week. VMCL engages ~1,850 calls per day, sees an additional 300 contacts through chat and text programs, and offers ~360 referrals per day to local VA Suicide Prevention Coordinators who contact Veterans to ensure continuity of care with local VA providers. VMCL consistently exceeds performance targets. In 2019, VCL responders answered 96.82% of calls in 20 s or less with an average speed of 9.92 s, maintained an abandonment rate of 2.78%, had a rollover rate of 0.027% which was a 98% reduction in rollovers from FY18.

Examples of Va's Community-Based Prevention Strategies

Of the 17 veterans who die by suicide every day, nine have never received VHA services and two have not received VHA services within the last 2 years. Moving upstream and reaching outside VA's walls to engage veterans in the community in lifelong health, well-being, and resilience is a critical part of VA's National Strategy. Community prevention focuses addressing social determinants of health outside the VHA healthcare system to promote early awareness and prevention prior to times of crisis, while also expanding collaboration and coordination of services across all veterans, families, Non-VHA healthcare systems, other community partners, and the VA. Community-based interventions are science-based approaches to changing community systems and contexts to improve population health outcomes ( 17 ), and these have been shown to effectively reduce suicide rates in diverse communities around the world ( 18 ). Three examples of community prevention models that have shown promise, Governor/ Mayoral Challenges VISN Community Prevention Pilots, and Together with Veterans are outlined below. VA is currently actively deploying all three and supports them with technical assistance. The interrelation among these programs is seen in the figure.

Governor's and Mayor's Challenges

In 2018, VA partnered with the Substance Abuse and Mental Health Service Administration (SAMHSA) to launch Mayor's Challenge and in 2019 it expanded these efforts to launch the Governor's Challenges. These challenges engage both government and community partners in the development of regionally developed interagency strategic plans to address veteran suicide through the deployment of evidence-based strategies. The Mayor's Challenge currently consists of 24 cities and counties. Since the program's inception in 2019, seven states have joined the Governor's Challenges and the program is expanding to 28 additional states over the next 2 years and then with a final goal of engaging all 50 states. City and states are provided with technical assistance and support through site visits, policy academies, and virtual consultation to enhance their plans and incorporate evidence-based strategies to reach out to all veterans in their local areas to prevent suicide, pairing state-level policy makers with local leaders to implement comprehensive plans.

VISN Community Prevention Pilots

Over the past year, the Office of Mental Health and Suicide Prevention partnered with Veterans Integrated Service Network (VISN) 23 in developing a pilot program to promote community prevention strategies to reach veterans through community engagement and partnerships focused upon coalition building at the local level. Implementation scientists from the University of Pittsburgh's Program Evaluation and Research Unit (PERU) and VA leadership worked collaboratively to provide technical assistance and facilitation hire and support 10 Community Engagement and Partnership Coordinators (CEPCs). CEPCs supplement the work of VA's 450+ suicide prevention coordinators by focusing on expanding community efforts to increase awareness of veteran suicide and moving awareness to engagement of local coalitions to implement community-focused evidence-based suicide prevention strategies. The CEPCs will collaborate at the community, regional, and state levels, to implement community partnerships, Together with Veterans, and the Governor's Challenge. Program evaluation efforts are now underway with planned expansion to three other VISNs this year, with an ultimate goal of engaging all 18 VISNs.

Together With Veterans (TWV)

TWV is a community-based suicide prevention program for rural Veterans ( 19 ), which is focused upon partnering rural veterans and their communities to implement community-based suicide prevention. Based in implementation science, TWV assists veterans in the community in implementing evidence-based suicide prevention strategies to reach rural veterans. TWV is a VA Office of Rural Health program focused on empowering and supporting Veteran to Veteran coalition building. This includes efforts to increase lethal means safety, gatekeeper training, training of primary care providers, stigma reduction and help-seeking behavior promotion, increasing access to crisis services, and enhancing efforts to support veterans at highest risk for suicide ( 19 ). Currently, TWV is deployed in several rural regions with additional sites being added the 2020 calendar year.

Suicide prevention is the top clinical priority for VA and a priority for public health across the globe. VA has embarked on a comprehensive program of clinically-based and community-based strategies within a public health framework guided by the research currently available. The above strategies are just a few examples of VA's overarching plan to employ a public health model in the deployment of Suicide Prevention 2.0 over the coming decade combined with specific strategies for implementation now to not only prevent death, but engage Veterans on a journey of health, well-being, and resilience throughout the course of their lifetime. A critical aspect of Suicide Prevention 2.0 is a simultaneous, comprehensive evaluation of its impact, addressing quality, accountability, integrity, and effectiveness, and VA is committed to a transparent assessment and how this compares with initiatives in other sectors. Although suicide prevention is a core responsibility for VA and for all healthcare systems, the mission of suicide prevention cannot be fully achieved by any system. This is an urgent matter that requires a broad public response but one that is adapted to each individual circumstance. There will never be a “one and done” solution. The programs and initiatives outlined in this paper represent the current iteration of VA's committed effort to prevent suicide, but there is much more to learn and to do and for that we need to respond as a nation in recognition and gratitude for the service given by all those who are veterans.

Author Contributions

DC: principal author, outlined, and drafted manuscript. LK and MM: edited and contributed content. All authors contributed to the article and approved the submitted version.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer AEM declared a shared affiliation with the authors to the handling editor at time of review.