The rates and patterns of suicidal behavior among U.S. Veterans differ from those of non-Veteran Americans. Although Veterans make up just over 8% of the adult population, they account for 14% of all deaths by suicide. In the last decade, there has been an increase in the rate of suicide among younger Veterans as well as gender-based differences in suicide rates (USDVA, 2019).
When service members leave the military, they lose the structure and support they experienced during their service. Missing one's team and no longer having a mission can lead to feelings of isolation, inadequacy, unrest, alienation, anxiety, and lack of purpose. During deployment, family members may have become more independent and self-reliant and service members may feel less needed, believing the family can survive just fine without them. Close, intense relationships that are formed within units become disrupted and lost when deployment ends.
VA Experience with Suicide
Users of Veteran’s Administration services account for about 5 suicides per day. Approximately half had a diagnosis of a mental health condition recorded in their medical records in the year prior to their death, and approximately three-fourths, within the past five years.
Source: DVA/DOD, 2013.
According to U.S. Department of Veterans Affairs data:
- Firearm injuries accounted for about 67% of all veteran deaths by suicide.
- Veterans over the age of 50 accounted for about 65% of all deaths by suicide.
- Veterans had a 21% higher risk for suicide compared to civilian adults.
- Male veterans had an 18% higher risk for suicide compared to civilian adult males.
- Female veterans had a 2.4 times higher risk for suicide compared to civilian adult females. (USDVA, 2016a)
A 2009 Department of Defense reportfound that only 7% of military suicides occurred among service members with multiple deployments. While half of those who committed suicide had been deployed at some time to Iraq or Afghanistan, only 17% experienced combat. Most suicides occurred among junior enlisted troops (WSDOH, 2016).
Among male veterans, suicide rates are highest in younger and older men. Among female veterans, suicide rates are highest in younger women. However, because the age distribution of the living veteran population is heavily weighted toward middle-aged adults, the resulting burden of suicide, in terms of the number of lives lost, is highest among middle-aged veterans, despite the lower rates of suicide observed for this sub-population (USDVA, 2016a).
Risk and Protective Factors
In a recent survey, veterans identified suicide as the most formidable challenge they face (DeBeer et al., 2016). Factors that appear to increase the risk of suicide among service members and veterans include:
- Being a young, unmarried male of low rank
- Having recently returned from deployment, especially if experiencing health problems
- Having had an adverse deployment experience
- Having experienced lack of advancement or reduction in rank
- Having a perceived loss of honor, sense of injustice, or betrayal
- Having difficulty with heavy drinking or other substance use problems
- Having been disciplined
- Experiencing mental health problems
- Experiencing a career-threatening change in fitness for duty
- Feeling command/leadership stress
- Feeling a sense of isolation from one’s unit
- Transferring to a new duty station
- Deploying to a combat theater (WSDOH, 2016)
Being a child in a military family is a risk factor for suicidal ideation. A higher percentage of tenth-graders with parents in the military reported symptoms of depression compared to tenth-graders from civilian families. They also answered yes more frequently to questions about serious consideration of suicide, making a suicide plan, and attempting suicide, and fewer than half answered yes when asked if there were adults to whom they could turn for help when feeling sad or hopeless (WSDOH, 2016).
PFC Shania Wilson
Private First Class Shania Wilson serves in the Washington State Army National Guard. A mother of three, she was stationed at Joint Base Balad, Iraq, for eight months, providing security for the hospital and Iraqi business on base, escorting local nationals working on base, and providing personal security detail services.
A second deployment sent PFC Wilson to Afghanistan. “I wasn't supposed to be on that deployment, but I was called to duty and had to go,” reported Shania. She pulled security duty in a variety of places and on several occasions experienced firefights; she also witnessed the death of three members of her unit, applied first aid to the severely wounded, and experienced two blasts from IED. She recalls being lightheaded with ringing in her ears. Since that time Shania has had problems thinking and remembering, has become more irritable, and experiences sleep disturbances.
After her deployments, Shania enrolled in college. On her arrival to school, she felt isolated and uncomfortable. She felt hopeless, as if there was no reason to live other than her children and unit, and she began to drink heavily. Several students in one of her classes surmised she was in the military and Shania overheard them refer to her one day as a “baby killer.”
Recently, a video was shown in her science course that made her feel uncomfortable and since that time she’s had more difficulty concentrating on her studies. She has not sought any medical or behavioral health assistance for fear that it could interfere with her career in the National Guard and also remove her from the chance to support her unit on another upcoming deployment. In fact, her team received notices that they could be tapped for an upcoming deployment.
Source: Schmidt, 2012.
Some factors appear to decrease the risk of suicide among service members and veterans. These protective factors are anything that makes it less likely for a person to develop a disorder. For service members and veterans, protective factors include:
- Strong interpersonal bonds
- Community support
- Intact marriage
- Child-rearing responsibilities
- Responsibilities or duties to others
- A reasonably safe and stable environment
Personal traits can also act as protective factors against suicide:
- Willingness to seek help
- Good impulse control
- Skills in problem solving, coping, and conflict resolution
- Sense of belonging, sense of identity, and good self-esteem
- Cultural, spiritual, and religious beliefs about the meaning and value of life
- Optimistic outlook—identification of future goals
- Constructive use of leisure time
Access to healthcare, participation in treatment, and a sense of the importance of health and wellness are also important protective factors for service members and veterans.
Treating PTSD and Depression
Among veterans returning from the current wars, one of the most common mental health diagnoses is post traumatic stress disorder (PTSD), which is a known risk factor for suicidal ideation and behavior. Major depressive disorder, which is highly comorbid with PTSD, independently increases risk for suicidal ideation and attempts (DeBeer et al., 2016).
Veterans with PTSD who feel they have purpose and meaning in life have better outcomes than those who do not. Social support is associated with lower PTSD symptom severity in trauma-exposed individuals. Disrupted sleep is a core symptom of PTSD, and research demonstrates that cognitive-behavioral treatments that reduce insomnia and nightmares can reduce other symptoms of PTSD (DeBeer et al., 2016).
A relationship exists between health-promoting behaviors—such as regular exercise and good nutrition—and PTSD symptoms. Adults who participated in an exercise intervention program showed decreased levels of PTSD symptoms compared to baseline, and this reduction lasted after the intervention was completed (DeBeer et al., 2016).
Major depressive disorder, which is highly comorbid with PTSD, independently increases risk for suicidal ideation and attempts. Identifying modifiable factors such as depression that could reduce the association between PTSD symptoms and suicidal ideation is a high research priority (DeBeer et al., 2016).
The VA Translating Initiatives for Depression into Effective Solutions (TIDES) projectuses a depression care liaison to link primary care and mental health services. The depression care liaison assesses and educates patients and follows up with both patients and providers to optimize treatment between primary care visits. This brings mental health care to the primary care setting, where most patients are first evaluated. An evaluation of TIDES found significant decreases in depression severity scores among 70% of primary care patients. TIDES patients also demonstrated 85% and 95% compliance with medication and followup visits, respectively (Stone et al., 2017).
The TIDES project has provided guidelines for collaboration between mental health and primary care specialists with support for assessment and triage, patient education, and proactive followup of patients with symptoms of depression. The guidelines have helped VA integrate collaborative care for depression into primary care settings throughout the VA healthcare system (USDVA, 2016b).
The Veterans Administration has developed a number of additional suicide prevention programs.
The United States Air Force Suicide Prevention Program has been particularly successful in addressing and changing the culture surrounding suicide. The program uses leaders as role models and agents of change, establishes expectations for behavior related to awareness of suicide risk, develops population skills and knowledge, and investigates every suicide. The program represents a fundamental shift from viewing suicide and mental illness solely as medical problems and instead sees them as larger service-wide problems impacting the whole community (Stone et al., 2017).
The suicide prevention program has been associated with a 33% relative risk reduction in suicide. It has also been associated with relative risk reductions in related outcomes, including moderate and severe family violence, homicide, and accidental death. An assessment comparing suicide rates before and after the launch of the program found significantly lower rates of suicide after the program was launched (Stone et al., 2017).
A Soldier’s Story
A soldier who had joined the Washington National Guard after returning from deployment came into the Joint Services Support (JSS) office at Camp Murray, WA asking for help finding a job. While talking with the Employment Transition Team, the soldier revealed financial struggles, fear of returning home because of domestic violence, overwhelming depression, and suicidal thoughts.
The JSS multidisciplinary team sprang into action. Five weeks later the soldier had a regular therapy schedule, gift cards for food and gas, an electronic benefits card, a refreshed resume, a suicide prevention mentor, an order of protection against the abusive partner, and safe transitional housing. Outstanding disability claims were resolved, and, as the soldier was about to move into an apartment, a job offer came through from a prominent Washington company. The soldier’s life moved from a place of desperation to a place of stability.
Source: WSDOH, 2016.
It is not unique for a person seeking help to have multiple needs spanning many systems. What is unique is that this soldier had the ability to get all of these needs met in one place by a collaborative, supportive team of professionals, each of whom was well-trained and attuned to depression and suicide risk.
The JSS states that its purpose is to “enhance the quality of life for all Guard members, their families, and the communities in which they live and contribute to readiness and retention in the Washington National Guard.” The JSS at Camp Murray combines strong and supportive leadership, cross-system teamwork, and attention to soldiers’ emotional needs and ability to thrive at work—a program model that improves job performance and saves lives.