In a tragic and disturbing trend, veterans are resorting to suicide on the grounds of VA facilities, VA Secretary Dr. David Shulkin said last week.

"As some of you may know, veterans tend to come to a VA -- either drive a car or come to the VA -- and actually suicide on our property," Shulkin said last Tuesday, stressing the need for the Department of Veterans Affairs to do more to curb veteran suicides, estimated at 20 daily nationwide.

"There are a number of reasons, not all of which I completely understand," for veterans to choose to end their lives at the VA, he said, "but one of them being they don't want their families to have to discover them."

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"They know that if they're discovered at a VA, that we will handle it in an appropriate way and take care of them," Shulkin said in his opening remarks at the VA's annual "Innovation Day" at Georgetown University.

Shulkin, who has made curbing veteran suicides his top clinical priority, did not state how many suicides are occurring at VA facilities, "but every day I am notified of more and more of these that happen. So we just have to do more, we have to do better, we have to innovate" in seeking out and assisting at-risk veterans.

VA officials also did not put a number on what is known in the veterans community as "parking lot suicides."

Shulkin "was referring to a number of tragic incidents that have been in the news," a VA spokesman said in an e-mail. "His point was that VA has more work to do when it comes to its suicide prevention efforts."

Dying at the VA

In an August 2016 incident reported by the Suffolk County police in New York, a 76-year-old Navy veteran died by suicide in the parking lot of the Northport Veterans Affairs Medical Center on Long Island, where he had been a patient.

Peter A. Kaisen, of Islip, Long Island, who also was a former police officer, was pronounced dead after he shot himself outside Building 92, the nursing home at the medical center, police said.

The reason for the suicide was not immediately known, but The New York Times reported that two people connected to the hospital who spoke on grounds of anonymity said the veteran had been frustrated he was unable to see an emergency-room physician for reasons related to his mental health.

The Northport Veterans Affairs Medical Center later said Kaisen had not been denied treatment.

In November 2016, the body of John Toombs, a former Army sergeant and Afghanistan veteran, was found hanged in a vacant building on the grounds of the Alvin C. York VA Medical Center in Murfreesboro, Tennessee.

Toombs left behind a video in which he said, "Earlier today, I was discharged for trivial reasons. They knew the extent of my problems. When I asked for help, they opened up a Pandora's box inside of me and kicked me out the door."

In February this year, the body of 63-year-old Navy veteran Paul Shuping was found in the parking garage of the Durham Veterans Affairs Medical Center in North Carolina six days after he took his own life. Police said Shuping used a .22-caliber rifle to kill himself inside a parked car in the garage.

Of particular concern to the VA was the death in March this year of Hank Brandon Lee, 35, a former Marine lance corporal who served tours in Iraq and Afghanistan.

He fatally overdosed on fentanyl while under lockdown at the Department of Veterans Affairs psychiatric facility in Brockton, Massachusetts. His family has demanded to know how he obtained the drugs.

Risk of Opioid Abuse

Last week, the office of the VA's Inspector General released a report stating that veterans using the VA's Choice program allowing private-sector health care face a "significant risk" of opioid abuse in the treatment of chronic pain.

Policies in place at the VA to reduce the number of opioid prescriptions do not necessarily apply to private-sector doctors, the IG said.

In a report titled "Opioid Prescribing to High-Risk Veterans Receiving VA Purchased Care," the IG said there is an overall lack of communication between the VA and private-sector doctors on what drugs should be prescribed.

"Veterans receiving opioid prescriptions from VA-referred clinical settings may be at greater risk for overdose and other harm because medication information is not being consistently shared," said VA Inspector General Michael Missal in a statement.

"That has to change," he said. "Health-care providers serving veterans should be following consistent guidelines for prescribing opioids and sharing information that ensures quality care for high-risk veterans."

The report highlighted the main problem: "Under Choice, prescriptions for veterans who are authorized care through Choice are required to be filled at a VA pharmacy," but "a veteran can choose to fill the prescription outside the VA and pay for the prescriptions with his or her own funds."

The report said, "With the expansion of community partnerships, a significant risk exists for patients who are prescribed opioid prescriptions outside of VA."

However, Shulkin said last week at the Innovation forum that "the fundamental way to fix the system is to give veterans more choice."

Extending Choice

On Saturday, Shulkin joined President Trump at his Bedminster, New Jersey, golf club for the signing of a $2.1 billion bill extending the Veterans Choice Program for another six months while Congress and the VA work on reforms.

Shulkin said last week that the veteran suicide rate is "absolutely unacceptable" and briefly outlined the VA's commitment to bringing the rate down.

In 2013, the VA released a study on suicides from 1999 to 2010, which showed that roughly 22 veterans were dying by suicide per day, or one every 65 minutes. The report relied on data from 20 states.

In August 2016, the VA released what was billed as the "most comprehensive analysis of veteran suicide rates" ever conducted, which examined more than 55 million veterans' records from 1979 to 2014 from all 50 states.

"The current analysis indicates that in 2014, an average of 20 veterans a day died from suicide" -- or one every 72 minutes, the report said.

The data also showed that only six of the 20 veterans who die in the U.S. each day are enrolled in the VA and only three are in active treatment, indicating a need for more outreach by the VA.

The VA's report said that about 65 percent of all veterans who died from suicide in 2014 were 50 years of age or older, and veterans accounted for 18 percent of all deaths from suicide among U.S. adults, a decrease from 22 percent in 2010.

Increasing Suicide Rates

Since 2001, U.S. adult civilian suicides increased 23 percent, while veteran suicides increased 32 percent in the same time period. "After controlling for age and gender, this makes the risk of suicide 21 percent greater for veterans," the 2016 report said.

Since 2001, the rate of suicide among veterans who use VA services increased by 8.8 percent, while the rate of suicide among veterans who do not use VA services increased by 38.6 percent, the report said.

The report went on to list a number of new measures on suicide prevention that the VA had in place or planned to implement before the end of 2016.

The steps included a toll-free Veterans Crisis Line (1-800-273-8255, press 1); the placement of Suicide Prevention Coordinators at all VA Medical Centers and large outpatient facilities; and improvements in case management and tracking.

The VA was also working to ensure same-day access for veterans with urgent mental health needs at more than 1,000 VA facilities by the end of 2016, the report said. In fiscal 2015, more than 1.6 million veterans received mental health treatment from the VA.

In addition, the VA was hiring more than 60 new crisis intervention responders for the Veterans Crisis Line. Each responder was to receive "intensive training on a wide variety of topics in crisis intervention, substance use disorders, screening, brief intervention, and referral to treatment," the report said.

-- Richard Sisk can be reached at Richard.Sisk@Military.com.