Defense Health Care: DOD Needs to Fully Assess Its Non-clinical Suicide Prevention Efforts and Address Any Impediments to Effectiveness

What GAO Found

The Department of Defense (DOD) has a variety of suicide prevention efforts that are implemented by the military services (Army, Navy, Air Force, and Marine Corps). These include clinical prevention efforts that are generally focused on individual patient treatment and interventions, as well as non-clinical efforts that are intended to reduce the risk of suicide in the military population. This includes, for example, training servicemembers to recognize warning signs for suicide and encouraging the safe storage of items such as firearms and medications.

Officials with DOD’s Defense Suicide Prevention Office (DSPO) told GAO that most ongoing non-clinical efforts are evidence based. Officials added that a suicide prevention effort is considered to be evidence based if it has been assessed for effectiveness in addressing the risk of suicide in the military population, which has unique risk factors such as a higher likelihood of experiencing or seeing trauma. These officials stated that newer efforts are generally considered to be “evidence informed,” which means that they have demonstrated effectiveness in the civilian population, but are still being assessed in the military population.

DSPO officials further explained that assessments of individual prevention efforts can be challenging because suicide is a complex outcome resulting from many interacting factors. In 2020, DSPO published a framework for assessing the collective effect of the department’s suicide prevention efforts by measuring outcomes linked to specific prevention strategies, such as creating protective environments. However, this framework does not provide DOD with information on the effectiveness of individual non-clinical prevention efforts. Having a process to assess individual efforts would help DOD and the military services ensure that their non-clinical prevention efforts effectively reduce the risk of suicide and suicide-related behaviors.

GAO also identified impediments that hamper the effectiveness of DOD’s suicide prevention efforts, including those related to the reporting of suicide data.

  • Definitions. The military services use different definitions for key suicide-related terms, such as suicide attempt, which may result in inconsistent classification and reporting of data. These data are used to develop the department’s annual suicide event report. DOD officials stated that this could negatively affect the reliability and validity of the reported data, which may impede the department’s understanding of the effectiveness of its suicide prevention efforts and limit its ability to identify and address any shortcomings.
  • Annual suicide reports. DOD publishes two yearly suicide reports through two different offices that are based on some of the same data and provide some of the same information, resulting in the inefficient use of staff. While these reports serve different purposes, improved collaboration between the two offices could help minimize duplication of effort and improve efficiency, potentially freeing resources for other suicide prevention activities.

Why GAO Did This Study

Suicide is a public health problem facing all populations, including the military. From 2014 to 2019, the rate of suicide increased from 20.4 to 25.9 per 100,000 active component servicemembers. Over the past decade, DOD has taken steps to address the growing rate of suicide in the military through efforts aimed at prevention.

The National Defense Authorization Act for Fiscal Year 2020 included a provision for GAO to review DOD’s suicide prevention programs. This report examines DOD’s suicide prevention efforts, including, among other objectives, (1) the extent to which non-clinical efforts are assessed for being evidence based and effective and (2) any impediments that hamper the effectiveness of these efforts.

GAO examined suicide prevention policies, reports, and assessments and interviewed officials from DOD, the military services, and the Reserve components. GAO also interviewed officials at four installations and a National Guard site selected for variety in military service, location, and size.

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    The Food and Drug Administration (FDA) has taken steps intended to improve safety at its laboratories, including those that work with hazardous biological agents. Specifically, FDA created the Office of Laboratory Safety (OLS) in 2017 as a safety oversight body for all FDA laboratories. Establishment of FDA's Office of Laboratory Safety (OLS) Note: Prior to March 2019, OLS was referred to as the Office of Laboratory Science and Safety. In coordination with FDA's operating divisions—known as centers—OLS has standardized safety policies, incident reporting, inspections, and safety training. However in creating OLS, FDA did not implement key reform practices that could have helped ensure OLS's effectiveness. For example, FDA's centers and OLS did not reach a shared understanding of OLS's roles and responsibilities—a key practice for effective agency reforms. Although senior agency leaders were involved in developing OLS's strategic plan, disagreements about OLS's role raised by center directors at that time still remain. For example, center directors told GAO that OLS's mission should not include science, laboratory quality management, or inspections. Conversely, the director of OLS said OLS remains committed to its mission as envisioned in the strategic plan, which includes these areas of responsibility. FDA officials said they plan to update the plan in 2021, which presents an opportunity for FDA to address areas of disagreement. In its current form, FDA's laboratory safety program also does not meet the key elements of effective oversight identified in GAO's prior work. For example, The oversight organization should have clear authority to ensure compliance with requirements. However, as part of a 2019 reorganization, FDA placed the OLS director at a lower level than the center directors. Also, OLS does not directly manage the center safety staff responsible for ensuring the implementation of safety policies that OLS develops. As a result, OLS has limited ability to access centers' laboratories—in part because they cannot inspect them unannounced—or to ensure compliance with safety policies. The oversight organization should also be independent from program offices to avoid conflict between program objectives and safety. However, OLS depends on the centers for much of its funding and has had to negotiate with the centers annually for those funds, which can allow center directors to influence OLS priorities through the funding amounts they approve. FDA has not assessed potential independence risks from using center funds for OLS. Without taking steps to do so, FDA's laboratory safety program will continue to compete with the centers' mission objectives and priorities. In 2014, FDA discovered improperly stored boxes of smallpox virus, posing a risk to individuals who might have been exposed. This raised concerns about the oversight of FDA's laboratories that conduct research on hazardous biological agents. In 2016, GAO made five recommendations to improve FDA's laboratory safety, four of which the Department of Health and Human Services (HHS) had not fully implemented as of July 2020. GAO was asked to examine FDA's efforts to strengthen laboratory safety. This report examines FDA's efforts since GAO's 2016 report to improve safety in its laboratories that work with hazardous biological agents. To conduct this work, GAO reviewed FDA documents; assessed FDA's safety oversight practices against key reform practices and oversight elements GAO identified in prior work; and interviewed FDA officials, including staff and senior leaders at OLS and the three centers that work with hazardous biological agents. GAO is making five recommendations to FDA, including to resolve disagreements over roles and responsibilities, to provide OLS with the authority and access to facilities necessary to oversee laboratory safety, and to take steps to assess and mitigate any independence risks posed by how OLS is funded. HHS agreed with all five recommendations. For more information, contact Mary Denigan-Macauley at (202) 512-7114 or deniganmacauleym@gao.gov.
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  • Native American Youth: Agencies Incorporated Almost All Leading Practices When Assessing Grant Programs That Could Prevent or Address Delinquency [Reissued with revisions on Aug. 27, 2020.]
    In U.S GAO News
    The Departments of Justice (DOJ), Health and Human Services (HHS), the Interior (Interior), and Education (Education) administered at least 38 grant programs from fiscal years 2015 through 2018 that could have helped prevent or address delinquency among Native American youth. These agencies made about $1.9 billion in awards to grantees through these programs during this period. These agencies incorporated almost all of the leading practices GAO identified for performance measurement or program evaluation when assessing the performance of selected grant programs. For example, HHS's Administration for Children and Families (ACF) incorporated 13 of the 14 leading practices for performance measurement but did not fully assess grantee data reliability for one of its programs. By developing a process to assess the reliability of grantee data contained in the annual performance reports that tribal recipients submit, ACF could obtain further assurance that it has an accurate representation of grantee performance. GAO also found that Interior's Bureau of Indian Education (BIE) did not conduct formal data reliability checks on performance data that grantees report and did not always collect performance reports from grantees in a timely manner for one of its programs. By developing a process to assess the reliability of a sample of grantee performance data and taking steps to alert grantees when they are late in submitting performance reports, BIE could better ensure that grantees are complying with the terms and conditions of the grant program and better understand how the program and its grantees are performing. Officials in all 12 interviews with tribes or tribal consortia GAO interviewed cited risk factors that contribute to juvenile delinquency in their communities. Number of Interviews in Which Tribal Officials Cited Risk Factors Contributing to Juvenile Delinquency Note: The figure includes the most common risk factors tribal officials cited for juvenile delinquency. While tribal officials cited restrictions placed on federal grant funding, difficulty communicating with program staff, and challenges hiring and retaining staff as barriers to implementing federal programs, they also identified promising practices, such as executing culturally relevant programs, for preventing or addressing juvenile delinquency. Federal and other studies have noted that exposure to violence and substance abuse make Native American youth susceptible to becoming involved with the justice system. GAO was asked to examine federal and tribal efforts to address juvenile delinquency and the barriers tribes face in doing so. This report examines (1) federal financial assistance targeting tribes that could prevent or address juvenile delinquency; (2) the extent to which federal agencies assess the performance of selected grant programs and incorporate leading practices; and (3) the juvenile delinquency challenges tribes report facing. GAO identified relevant grant programs during fiscal years 2015 through 2018—the most recent data available when GAO began the review. GAO analyzed documents and interviewed agency officials to determine how they assessed grant program performance and conducted interviews with 10 tribes and two tribal consortia to discuss challenges with delinquency. GAO is making three recommendations, including that relevant HHS and Interior offices develop a process to assess the reliability of tribal grantee performance information and that an Interior office take steps to alert grantees that are late in submitting progress reports. Interior concurred with the two recommendations. HHS disagreed with GAO's recommendation. GAO clarified the recommendation to HHS and continues to believe it is warranted. For more information, contact Gretta L. Goodwin, (202) 512-8777, or GoodwinG@gao.gov.
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    Four Eastern European nationals have pleaded guilty to conspiring to engage in a Racketeer Influenced Corrupt Organization (RICO) arising from their providing “bulletproof hosting” services between 2008 and 2015, which were used by cybercriminals to distribute malware and attack financial institutions and victims throughout the United States.
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  • Anti-Money Laundering: FinCEN Should Enhance Procedures for Implementing and Evaluating Geographic Targeting Orders
    In U.S GAO News
    To combat money laundering, the Financial Crimes Enforcement Network (FinCEN) issued a geographic targeting order (GTO) in 2016 that required title insurers to report information on certain all-cash purchases of residential real estate by legal entities in specified areas. According to FinCEN analysis, the use of legal entities to purchase high-value real estate, particularly in certain U.S. cities, was prone to abuse. FinCEN determined that imposing the real estate GTO reporting requirements on title insurers would cover a large number of transactions without unnecessary complexity. FinCEN renewed the real estate GTO multiple times—finding it has yielded information useful to law enforcement investigations—and periodically expanded the types of monetary instruments and geographic areas included and decreased the price reporting threshold (see fig.). Issuance and Renewals of the Real Estate Geographic Targeting Order (GTO) Unlike prior GTOs, which FinCEN officials said they issued at the request of and with the involvement of law enforcement agencies, FinCEN issued the real estate GTO on its own initiative. Thus, FinCEN had to take the lead in implementing and evaluating the GTO but lacked detailed documented procedures to help direct the GTO's implementation and evaluation—contributing to oversight, outreach, and evaluation weaknesses. For example, FinCEN did not begin examining its first title insurer for compliance until more than 3 years after issuing the GTO and did not assess whether insurers were filing all required reports. Similarly, while FinCEN initially coordinated with some law enforcement agencies, it did not implement a systematic approach for outreach to all potentially relevant law enforcement agencies until more than 2 years after issuing the GTO. FinCEN also has not yet completed an evaluation of the GTO to determine whether it should address money laundering risks in residential real estate through a regulatory tool more permanent than the GTO, such as a rulemaking. Strengthening its procedures for self-initiated GTOs should help FinCEN more effectively and efficiently implement and manage them as an anti-money laundering tool. Bad actors seeking to launder money can use legal entities, such as shell companies, to buy real estate without a loan. Doing so potentially can conceal the identities of bad actors and avoid banks' anti-money laundering programs. To better understand this risk and help law enforcement investigate money laundering, FinCEN issued its real estate GTO. Although GTOs are limited to 180 days, they may be renewed if FinCEN finds reasonable grounds for doing so. Because of concerns about the potential for bad actors to exploit regulatory gaps to launder money through the U.S. real estate market, GAO was asked to review FinCEN's real estate GTO. This report examines, among other things, the GTO's issuance and renewal, oversight, outreach, and evaluation. GAO reviewed FinCEN's records, orders, and policies and procedures; laws and regulations; and studies and other related materials. GAO also interviewed FinCEN, federal law enforcement agencies, and other stakeholders. GAO recommends that FinCEN provide additional direction for self-initiated GTOs, including how to plan for oversight, outreach, and evaluation. FinCEN concurred with GAO's recommendation. For more information, contact Michael E. Clements, (202) 512-8678, ClementsM@gao.gov.
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  • Justice Department Settles with Florida Towing Company it Alleges Illegally Sold or Scrapped Servicemembers’ Vehicles
    In Crime News
    The Justice Department today reached an agreement with ASAP Towing & Storage Company (“ASAP”) in Jacksonville, Florida, to resolve allegations that ASAP violated a federal law, the Servicemembers Civil Relief Act (“SCRA”), by auctioning off or otherwise disposing of cars owned by protected servicemembers without first obtaining court orders. 
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    In Crime News
    Good afternoon, everyone, and thank you for joining us today for a conversation on one of the most pressing challenges we face – the continuing fight against the online exploitation of children.  I want to thank Berit Berger and Columbia Law School for hosting us virtually, and for putting together this event on such an important subject.
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  • Justice Department Finds Yale Illegally Discriminates Against Asians and Whites in Undergraduate Admissions in Violation of Federal Civil-Rights Laws
    In Crime News
    The Department of Justice today notified Yale University of its findings that Yale illegally discriminates against Asian American and white applicants in its undergraduate admissions process in violation of Title VI of the 1964 Civil Rights Act. The findings are the result of a two-year investigation in response to a complaint by Asian American groups concerning Yale’s conduct.   
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  • GAO Audits Involving DOD: Status of Efforts to Schedule and Hold Timely Entrance Conferences
    In U.S GAO News
    GAO began 42 new audits that involved the Department of Defense (DOD) in the third quarter of fiscal year 2020. Of the 42 requested entrance conferences (i.e., initial meetings between agency officials and GAO staff) for those audits, DOD scheduled 41 within 14 days of notification and held all 42 entrance conferences within 30 days of notification. Scheduling was delayed for one entrance conference, which was scheduled 21 days after notification, because DOD and GAO were working to reach agreement on the primary action officer, which is the appropriate office or component within the department that coordinates DOD's response to the audit. The entrance conference was held 8 days after it was scheduled. Entrance conferences allow GAO to communicate its audit objectives and enable agencies to assign key personnel to support the audit work. GAO's agency protocols govern GAO's relationships with audited agencies. These protocols assist GAO in scheduling entrance conferences with key agency officials within 14 days of receiving notice of a new audit. The ability of the Congress to conduct effective oversight of federal agencies is enhanced through the timely completion of GAO audits. In past years, DOD experienced difficulty meeting the protocol target for the timely facilitation of entrance conferences. In Senate Report 116-48 accompanying a bill for the National Defense Authorization Act for Fiscal Year 2020, the Senate Armed Services Committee included a provision for GAO to review DOD's scheduling and holding of entrance conferences. In this report, GAO's agency protocols govern GAO's relationships with audited agencies. These protocols assist GAO in scheduling entrance conferences with key agency officials within 14 days of receiving notice of a new audit. The ability of the Congress to conduct effective oversight of federal agencies is enhanced through the timely completion of GAO audits. In past years, DOD experienced difficulty meeting the protocol target for the timely facilitation of entrance conferences. In Senate Report 116-48 accompanying a bill for the National Defense Authorization Act for Fiscal Year 2020, the Senate Armed Services Committee included a provision for GAO to review DOD's scheduling and holding of entrance conferences. In this report, GAO evaluates the extent to which DOD scheduled entrance conferences within 14 days of receiving notice of a new audit, consistent with GAO's agency protocols, and held those conferences within 30 days. This is the third of four quarterly reports that GAO will produce on this topic for fiscal year 2020. In the first two quarterly reports, GAO found that DOD had improved its ability to meet the protocol target. GAO analyzed data on GAO audits involving DOD and initiated in the third quarter of fiscal year 2020 (April 1, 2020, through June 30, 2020). Specifically, GAO identified the number of notification letters requesting entrance conferences that were sent to DOD during that time period. GAO determined the number of days between when DOD received the notification letter for each new audit and when DOD scheduled the entrance conference and assessed whether DOD scheduled entrance conferences within 14 days of notification, which is the time frame identified in GAO's agency protocols. GAO also determined the date that each requested entrance conference was held by collecting this information from the relevant GAO team for each audit and assessed whether DOD held entrance conferences for new audits within 30 days of notification, which was the time frame identified in the mandate for this review For more information, contact Elizabeth Field at (202) 512-2775 or Fielde1@gao.gov.
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  • Federalism: Opportunities Exist to Improve Coordination and Consultation with State and Local Governments
    In U.S GAO News
    Federal agencies' intergovernmental affairs activities advance agency objectives that require coordination with state and local governments. Most of the 24 Chief Financial Officers (CFO) Act agencies GAO surveyed reported undertaking similar information-sharing and coordination activities, such as serving as liaisons, conducting outreach, and hosting and attending events. The agencies GAO surveyed also reported taking varied approaches to structuring their intergovernmental affairs operations to conduct these activities. Of the 20 agencies with agency-wide intergovernmental affairs offices, half focused on intergovernmental affairs as their sole function while the other half included multiple functions, such as congressional or legislative affairs. How Agencies Organized Their Intergovernmental Affairs Operations Most agencies also reported that intergovernmental affairs activities and responsibilities were dispersed across their agencies. Regional and program offices perform intergovernmental affairs functions at some agencies, while others have an agency-wide office for them. Responsibilities for consulting with state and local governments under Executive Order (E.O.) 13132 also varied. The order requires that each federal agency designate an official to implement the order. Fourteen agencies reported having such an official; 10 did not report having one. Representatives from state and local associations GAO interviewed reported interacting with federal agency intergovernmental affairs offices for outreach and information-sharing purposes. They also cited coordination and consultation challenges, such as difficulty identifying intergovernmental affairs contacts, limited federal agency knowledge of state and local government, and inconsistent consultation on proposed regulations. The Office of Management and Budget (OMB) has primary responsibility for implementing E.O. 13132 and related implementation guidance, including a requirement for the designation of a federalism official. However, OMB could not identify any oversight steps it had taken to ensure federal agencies' designation of a federalism official consistent with its guidance for implementation of the executive order. Taking steps to ensure federal agencies' designation of a federalism official could help ensure that agencies have an accountable process in place for appropriately consulting with state and local governments. Federal programs fulfilling national goals in education, health care, transportation infrastructure, and homeland security, among other issues, are implemented through a complex partnership between federal, state, and local governments. E.O. 13132, Federalism, outlines principles and criteria to guide the formulation and implementation of policies and the appropriate division of responsibilities between levels of government. GAO was asked to review intergovernmental affairs activities at executive branch agencies. This report (1) identifies intergovernmental affairs offices' key responsibilities and activities at selected federal agencies and how these offices are organized, and (2) assesses state and local government officials' interaction with intergovernmental affairs offices, including their reported strengths and challenges. GAO examined relevant policies and executive orders and surveyed officials from the 24 CFO Act agencies. GAO also interviewed a nongeneralizable sample of individuals from 10 associations representing state and local government officials. GAO is recommending that OMB ensure that federal agencies implement its guidance on agency adherence to E.O. 13132 requirements, particularly related to designating a federalism official. OMB neither agreed nor disagreed with the recommendation. For more information, contact Michelle Sager at (202) 512-6806 or sagerm@gao.gov.
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    A federal grand jury in the U.S. District Court in Denver, Colorado, returned a superseding indictment charging six additional defendants for their roles in a previously indicted conspiracy to fix prices and rig bids for broiler chicken products, and containing additional allegations against the previously charged defendants in the same conspiracy, the Department of Justice announced today.  The superseding indictment also charges one defendant with making false statements and obstruction of justice. 
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