In mid-2010, more than 500 veterans were on a waiting list to receive mental health care at the Atlanta VA Medical Center. Sixteen attempted suicide before the VA, overwhelmed by a combination of surging demand and budget cuts, could fit them in.

The VA's solution, once funding improved, was to refer more vets to outside treatment facilities. These groups, most of them nonprofits known in VA lingo as "community service boards," or CSBs, provide outpatient counseling, crisis intervention, substance abuse treatment and other services. Then the VA reimburses them for those services.

By October, 2010, the waiting list had virtually disappeared, VA officials said.

In reality, though, the medical center had merely traded one problem for another, a review by The Atlanta Journal-Constitution found. By this time last year, 372 veterans were on a separate list, waiting for treatment from the CSBs.

They waited, on average, three months, according to a recent federal review. At least two who were referred committed suicide without ever getting treatment there.

The Atlanta center serves about 15,000 outpatient mental health patients; at the height of the program, about 4,000 were referred out under a contract that covered 26 CSBs throughout the state.

The VA Office of Inspector General found a referral system rife with problems: too few VA staff to oversee it, payment delays and a breakdown in communication between medical center and the CSBs.

The VA lost track of many veterans referred to the outside clinics. Based on a sample of 85 cases, reviewers estimated that one in five vets never received any care from a CSB or any follow-up by the VA. Some people waited more than a year for an appointment.

"They were basically overwhelmed and patients were falling through the cracks," said Murray Leigh, an official in the VA's Office of Inspector General.

Atlanta VA officials did not dispute the conclusions of the review, which was issued in April. The facility declined to make any officials available for interviews for this story. It provided a statement saying: "The facility is moving forward with its commitment to ensuring all veterans are receiving high quality health care and is closely monitoring mental health care and contract management."

One Sandy Springs veteran of the Iraq War felt the sting of the problems firsthand. (He requested anonymity in this story because he worries that public knowledge of his psychological issues would hurt his chances of finding a job.)

Unable to sleep, his anxiety peaking, the vet went to the Atlanta VA for treatment in 2010 and was referred to a community service board. When he called the CSB, a staffer told him the place had not received a referral. The vet checked back with the VA, which assured him it had issued a referral.

He tried for three months to resolve the confusion, he said. He found it difficult to get through to people at the VA. He said his problems with Post Traumatic Stress Disorder, the product of combat in Iraq, were so bad he could not work during that time. If anything, the bureaucratic muddle made his disorder worse.

"Mental health from the VA is just garbage," he said.

Eventually his mother gave him money to hire a private therapist.

Another vet fared far worse. This patient, whose case is described anonymously in the review, was having suicidal thoughts when he turned to the VA for help. He was told to contact a CSB for treatment, but didn't do so. After a month, VA staff tried to contact him, leaving him a voice mail message. After another month, he made an appointment with the CSB, but then postponed it.

Three months later, more than 200 days after his initial visit to the VA, he died of a drug overdose in a hotel room.

"Not knowing what happens after they give somebody a phone number and say, 'Good luck,' is inadequate care," said Kaye Coker, a licensed clinical social worker in Decatur who specializes in treating veterans.

Veterans are trained to ensure hardship; many don't reach out until they're truly desperate, Coker said. It's vital that help come quickly.

"That is your golden hour. That is the opportunity to help," Coker said. "There has to be some action there."

The VA inspectors had no trouble pinpointing the source of the problems: They found 10 VA employees managing the cases of over 4,000 vets referred to CSBs. Staffers complained of burnout and said they worried about patient safety, because they simply couldn't keep up with the numbers.

In addition, the contract between the VA and the CSBs was too vague, causing needless confusion and time-consuming questions. Problems with processing invoices caused payment delays that eventually led some CSBs to stop taking new VA patients.

Cindy McLaughlin, head of the CSB called Avita Community Partners, said her company had problems obtaining payment from the VA last year. "We were feeling some disconnect with communication," she said.

But Avita, which serves vets in Forsyth, Hall and 11 other counties in Northeast Georgia, never stopped serving VA patients. The VA has since placed a liaison with Avita to help resolve those problems.

Several other CSBs contacted by the AJC said they have a good working relationship with the VA. Nevertheless, the Atlanta center recently ended its contract with all but five of the CSBs.

Center officials are supposed to submit an "action plan" within the next few weeks to correct the problems found by the review. Top management has been replaced and some employees reprimanded.

Next week, Sen. Johnny Isakson, R-Ga., will chair a Senate Veterans' Affairs Committee field hearing on the Atlanta VA's mental health services at Georgia State University.

Last month, VA hospital director Leslie Wiggins, who assumed her post in May, said she has hired 17 additional mental health workers and implemented a new system to track patients. She also said the hospital has reduced wait times for mental health services, with nine in 10 vets receiving appointments within 14 days.

That's little solace to an Acworth veteran who felt brushed off by the VA.

On his initial visit, he said, a staffer sat him down and ran through a checklist of questions without ever looking him in the eye. When the vet complained that he felt dehumanized, the staffer called in a supervisor.

"They talked about me as though I wasn't in the room," said the vet, who requested anonymity because he did not want the public to know about his psychological condition.

He was referred to a CSB, but he never called to make an appointment and the VA never followed up, he said.

"What's the point?" he said. "If the VA could care less about service, what would their contractor be like?"