What happens when veterans can’t access the psychiatric care they need?

The secretary of veterans affairs, Denis McDonough, visited a clinic in Chico, California, last week and personally pledged to address concerns about inadequate staffing in the VA facility’s mental health unit.

His visit came after a ProPublica investigation revealed serious lapses in the psychiatric care two veterans received at the clinic. After years of struggling to get adequate treatment, and in the midst of mental health crises, the veterans shot and killed their mothers within days of each other in January 2022. The ProPublica story grew out of an inquiry by the VA’s inspector general that examined the agency’s shortcomings in one of the deaths.

At the time of the shootings, the clinic hadn’t had a full-time, on-site psychiatrist in five years, and many of the telehealth providers had recently stopped seeing Chico patients. Clinic employees told ProPublica they had begged regional leaders for help, but the federal health system was slow to respond. The former site manager told ProPublica she had warned colleagues, “We are going to kill someone.”

On Thursday, McDonough, who previously served as White House chief of staff and principal deputy national security adviser during the Obama administration, held a roundtable discussion with front-line mental health workers as well as top leaders from the VA’s regional office in Northern California.

“This is an important opportunity for us to learn really important lessons, and part of my learning today was to come up here to meet with our team to hear directly from them what their experience is right now and what I need to do to make sure that I’m the best possible partner for them,” he told a local news reporter after the meeting. “In that regard, this was a very, very helpful event.”

McDonough said he assured employees “that they would not be unheard in their concerns” and that the VA would “continue to make progress on staffing issues.”

“We have a very fast-growing veteran population here in Chico,” he added. “We have to make sure that we are growing commensurate with that population so that they can get the timely access to care and the timely access to benefits that they have earned. We’re making progress on that, but there’s still more work to be done, and we will not rest until we get it done.”

In a statement about the visit, VA Press Secretary Terrence Hayes said, “we take the issues raised by the VA’s inspector general and ProPublica extremely seriously, and we appreciate the oversight — which helps us better serve our nation’s Veterans.”

Hayes declined to say anything more specific about the actions McDonough intends to take.

ProPublica examined the case of Julia Larsen, a 29-year-old woman who was honorably discharged from the Navy in 2016. Upon returning home to California, Larsen was diagnosed with post-traumatic stress disorder from combat and military sexual trauma. She began experiencing psychotic symptoms soon after.

Marty Larsen displays a photo of his daughter Julia, which he keeps in his wallet. The photo was taken around the time of her boot camp graduation, just before deployment. Credit: Loren Elliott for ProPublica

Larsen sought help at the Chico clinic for several years, she told ProPublica and her medical records show. But she said the providers were too busy for talk therapy and focused instead on medications. In late 2021, a virtual nurse practitioner Larsen had never seen prescribed her two drugs that can trigger psychotic or manic symptoms when taken together. It isn’t clear which, if either, she took.

In January 2022, on a morning when Larsen was experiencing an extreme mental health crisis, a nurse at the Chico clinic mistakenly instructed Larsen’s mother to bring her in for an assessment. But the virtual nurse practitioner who was on call was booked and had no time for a consultation, violating VA rules that require patients to be seen in such situations. In addition, a social worker who was supposed to assess Larsen failed to follow protocols and sent her home.

Later that night, the sound of a far-off explosion frightened Larsen and prompted her to fire her handgun several times inside her parents’ home. One bullet pierced her mother in the thigh, damaging a large blood vessel and fatally wounding her.

Larsen’s case was the subject of a February 2023 report by the VA’s Office of Inspector General, which found the Chico clinic had failed to manage her medication, provide same-day access to care and assess her risk of violence. Larsen was later committed to a state-run forensic psychiatric hospital.

Andrew Iles, an Air Force veteran who was diagnosed with schizoaffective disorder, also struggled to get consistent treatment at the clinic, ProPublica found. His providers changed repeatedly. He was sometimes assigned to a pharmacist instead of a psychiatrist or psychologist.

A photo of Andrew Iles at boot camp is pictured at the home of his older sister, Ashley Hill. The family moved to Texas for a fresh start after Iles killed his mother. Credit: Loren Elliott for ProPublica

Over time, Iles’ delusions grew more extreme, and he came to believe his immediate family was trying to kill him. He shot his mother in January 2022, killing her in the home they shared.

After ProPublica’s investigation was published, Iles, 35, was found not guilty by reason of insanity. As a result, he will be committed to a state psychiatric hospital instead of facing prison time.

In a press release announcing the case’s resolution, the local district attorney, Michael L. Ramsey, linked to and cited ProPublica’s reporting, saying it showed Iles “had difficulty establishing consistent care with a mental health provider through the VA.”

In addition to the two cases, ProPublica analyzed more than 300 studies conducted by the agency’s inspector general over the last four years. The analysis found repeated failures in mental health care, some of which had fatal consequences.

Andrew’s older sister, Ashley Hill, said this week that she was disappointed the VA hadn’t reached out to her family directly or published an inspector general’s report on her brother’s case.

“If this leads to some kind of change,” she said of the secretary’s visit to Chico, “that’s the best thing my family can hope for.”