More than 6,000 veterans killed themselves each year between 2008 and 2016. In 2016, 202 people died by suicide in Georgia. And between 2015 and 2016, the suicide rate per 100,000 people for veterans ages 18 to 34 increased from 40.4 to 45 nationwide, despite the VA’s efforts to tackle the problem.

In 2013, the VA disclosed that two of its officials had retired, three had been reprimanded and others were facing unspecified “actions” after reports of rampant mismanagement and patient deaths at the VA hospital in Decatur. Federal inspectors issued scathing audits that linked mismanagement to the deaths of three veterans there.

In one case, a man who was trying to see a VA psychiatrist who was unavailable was told by hospital workers to take public transportation to an emergency room. He never did and died by suicide the next day. Another man died of an apparent drug overdose after providers failed to connect him with a psychiatrist. And a third patient died of an overdose of drugs given to him by another patient. The death of a fourth veteran, who killed himself in a hospital bathroom, later came to light.

In 2014, the Atlanta center drew attention again after the murder-suicide of Marine veteran Kisha Holmes. She killed her three children and then herself at the family’s Cobb County apartment. VA officials knew she was in distress and had identified her as a suicide risk.

And in November, the Government Accountability Office released a report saying the Veterans Health Administration had spent only $57,000 of the $6.2 million budgeted for fiscal year 2018 for suicide prevention media outreach because of leadership turnover and reorganization within the agency.

“By not assigning key leadership responsibilities and clear lines of reporting, VHA’s ability to oversee the suicide prevention media outreach activities was hindered and these outreach activities decreased,” the report said.

The VA said Monday it was reviewing its policies and procedures to see if changes are needed, adding all of its facilities provide “same-day urgent primary and mental health care services.” The agency also highlighted its Veterans Crisis Line at 1-800-273-8255 and www.veteranscrisisline.net

“Suicide prevention is VA’s highest clinical priority,” the VA said in a prepared statement. “We are working alongside dozens of partners, including [the Department of Defense], to deploy suicide prevention programming that supports all current and former service members — even those who do not come to VA for care.”

Isakson, chairman of the Senate Veterans’ Affairs Committee, released a statement Monday, saying he was in touch with the VA about its investigations of last weekend’s suicides, calling them “tragedies that we hear about far too often.”

“While we have taken a number of steps to address and prevent veteran suicide, this weekend’s tragic deaths clearly indicate that we must do better,” he said. “We will redouble our efforts on behalf of our veterans and their loved ones, including our efforts to reduce the stigma of seeking treatment for mental health issues.”

Mike Roby, commissioner of the Georgia Department of Veterans Service, said he also is keeping in touch with the VA about what happened.

“I and my senior staff will stay in close contact with both medical directors and their staff as they work with the federal authorities through the investigations,” he said by email. “Our field service officers located at both medical centers remain ready to assist and support veterans and their families.”

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In 2013, the Veterans Affairs Department disclosed that two of its officials had retired, three had been reprimanded and others were facing unspecified “actions” after reports of rampant mismanagement and patient deaths at the Atlanta VA Medical Center in Decatur. Federal inspectors issued scathing audits that linked mismanagement to the deaths of three veterans there. The Atlanta hospital drew attention again the following year after the murder-suicide of Marine veteran Kisha Holmes. She killed her three children and then herself at the family’s Cobb County apartment. VA officials knew she was in distress and had identified her as a suicide risk.