Suicide is a major public health issue and among the top ten causes of death in the United States. Unfortunately, for more than a decade, the suicide rate has been rising in the general U.S. population and especially among veterans, men and women who risked their lives for the country. This Veterans' Issues in Focus Perspective presents data on the magnitude of the problem, identifies particularly noteworthy issues and trends, highlights recent advances, and identifies gaps that deserve increased attention from both researchers and policymakers. In its 2018–2024 strategic plan, the U.S. Department of Veterans Affairs (VA) identified preventing veteran suicide as its highest clinical priority, and the RAND Epstein Family Veterans Policy Research Institute is committed to helping VA—and the country—achieve this critical goal.
In 2018, 6,435 veterans and 40,075 nonveteran adults died by suicide. But because there are many more nonveterans in the population, the rate of suicide among veterans was 32.0 per 100,000, compared with 17.2 per 100,000 for nonveterans (VA, 2020b).
For the past 12 years, suicide rates have been consistently higher among veterans than nonveterans. Furthermore, since 2005, the suicide rate has risen faster among veterans than it has for nonveteran adults. Figure 1 shows age- and sex-adjusted rates over time (which are better for comparing between groups); as of 2019, adjusted rates of suicide were 27.5 per 100,000 for veterans and 18.2 per 100,000 for nonveterans (VA, 2020b).
In 2018, the suicide rate among veterans 18–34 years old was 45.9 per 100,000—higher than in any other age group in either population and almost three times higher than for nonveterans in the same age bracket (16.5 per 100,000). This equated to 874 suicide deaths among veterans ages 18–34 (796 men and 78 women) in 2018.
In 2018, 2,587 veterans ages 55–74 died by suicide, a rate of 30.4 per 100,000 (compared with 17.0 per 100,000 among nonveterans in the same age bracket).
In 2018, the suicide rate for veteran women was 14.8 per 100,000 (291 deaths), almost twice the rate for nonveteran women (7.6 per 100,000). The difference was greatest among women ages 18–34 (veterans: 21.8; nonveterans: 6.8 per 100,000). That same year, the suicide rate among veteran men was 1.2 times the rate among nonveteran men (33.8 versus 29.0 per 100,000). For men, the difference was also greatest among 18- to 34-year-olds (veterans: 51.5; nonveterans: 26.4 per 100,000).
In 2018, 68.2 percent of veterans who died by suicide used a firearm, compared with 48.2 percent of nonveterans. Figure 2 shows these proportions overall and for men and women.
By many measures, the mental health care provided by VA through the Veterans Health Administration (VHA) is higher-quality than the care available through private providers, and, in some areas, it might be improving (O'Hanlon et al., 2017; VA, 2020b). However, the rate of suicide among VHA patients with a mental health or substance use disorder diagnosis was 57.2 per 100,000—more than double the rate among those without these diagnoses. Specifically, suicide rates were highest among VHA patients diagnosed with opioid use disorder or bipolar disorder (both between 120 and 130 suicide deaths per 100,000), followed by schizophrenia and substance use disorders overall (both between 80 and 100 deaths per 100,000), anxiety (67 per 100,000), depression (66.4 per 100,000), and posttraumatic stress disorder (between 50 and 60 per 100,000). There is also evidence that veterans with traumatic brain injuries are at increased risk of suicide compared with those without these injuries (Hostetter et al., 2019). There is mixed evidence about the role of combat exposure in suicide risk. In one study, among all service members who deployed from 2001 to 2007, deployment was not associated with increased suicide risk between 2001 and 2009 (Reger et al., 2015). However, among those who served in the active-duty Army between 2004 and 2009, suicide risk was elevated during active service for currently and previously deployed soldiers (Schoenbaum et al., 2014).
In 2012, VA and the U.S. Department of Defense (DoD) collaborated to create the VA/DoD Mortality Data Repository. Each year, VA and DoD generate a list of all veterans, nonveteran VA patients (such as the eligible dependents of veterans), and active-duty military personnel, which is matched to the National Death Index maintained by the Centers for Disease Control and Prevention (CDC). This produces a data set with causes of death for all veterans each year, regardless of their eligibility or use of VA benefits (Hoffmire et al., 2020).
The rate of veteran suicide, reflecting thousands of lives lost each year, warrants greater attention from VA, other federal agencies, state and local governments, and organizations that serve veterans. There have been some notable advances in research and practice that might help reduce suicide among veterans.
Screening all patients for suicide risk in mental health, emergency, and primary care settings can detect those who might be thinking about harming themselves, discern their current level of risk, and provide opportunities to offer appropriate care—ultimately reducing suicide attempts (Miller et al., 2017). Screening can be conducted efficiently using validated tools, such as the Ask Suicide-Screening Questions (ASQ) tool, across health care settings (Roaten et al., 2018; National Institute of Mental Health, undated; Thom, Hogan, and Hazen, 2020). As part of its National Strategy for Preventing Veteran Suicide, VA developed Risk ID, a three-stage suicide screening process that has been implemented successfully in VA settings (VA, 2018; Bahraini et al., 2020).
VA's ReachVet program applies statistical algorithms to clinical data to produce a monthly list of veterans with the highest probability of dying by suicide (Reger et al., 2019). A coordinator at each VA facility receives the list of at-risk patients and alerts the veterans' health care providers.
Caring contacts are brief, personal, nondemanding follow-up messages sent to patients after they receive care. These messages have been linked to decreased suicide attempts (Motto and Bostrom, 2001). VA now sends follow-up letters to veterans who receive care at a VA facility or call the Veterans Crisis Line and choose to identify themselves to the call responder (VA, 2020a). VA researchers are testing the approach with other patient populations, including those seen in VA emergency departments (Landes et al., 2019).
Several efforts have recently been launched to promote community-based approaches to suicide prevention. The CDC's community prevention framework has seven components, ranging from providing economic support to promoting connectedness and creating a protective environment (Stone et al., 2017). In partnership with VA, the Substance Abuse and Mental Health Services Administration (SAMHSA) recently issued a challenge (and is providing assistance) to governors and mayors across the United States to create and implement suicide prevention plans targeting service members, veterans, and their families. As of November 2020, 27 states and 18 communities were participating in the program (SAMHSA, 2020). Prior community-based initiatives similar in structure but focused on youth suicide prevention have produced promising results (Garraza et al., 2015, 2018, 2019).
Researchers have been engaged in multiple research efforts to address veteran suicide, and many studies are ongoing. There remains much to explore to better understand why veterans take their lives and how policies and practices could enable effective interventions.
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