Nationwide, more than 30,000 active-duty service members and veterans of the post 9/11 wars have died by suicide, significantly more than the 7,057 killed in combat. A disproportionate number of service members who die by suicide are young males in their twenties, white, non-Hispanic in the Army or Marine Corps (Suitt, 2021).

In 2024, suicide rates among active-duty military personnel rose by 10%, from 331 to 363. John Bateson, former executive director of a Bay Area crisis intervention and suicide prevention center, recommends multiple suicide evaluations for all troops returning from deployment, as well as their families. This should include rigorous reintegration training upon separation from the military, more efficient treatments and benefits for veterans, enforcing the stated policy of zero tolerance for sexual harassment and assault, and a major cultural shift to banish stigma around mental illness (Bateson, 2024).

Why U.S. military personnel and veterans are at increased risk for suicide compared to civilians is the focus of ongoing research. Key issues include military- and non-military-related trauma, combat-related experiences, military sexual assault, difficulty reintegrating into civilian life, and access to guns. Some have a history of childhood abuse and intimate partner violence, and high rates of posttraumatic stress disorder, a known risk factor for both suicidal ideation and behaviors (Holliday et al., 2020).

Despite efforts to address suicide among veterans and service members, little is known about what interventions they are willing to receive. A survey of communication and intervention preferences for veterans and service members found that nearly 90% of respondents indicated that they were willing to speak to someone when having thoughts of suicide. Most indicated they were far less likely to talk about their thoughts of suicide with non-military friends than military friends. They were also considerably less likely to talk about their thoughts of suicide with the Veterans Crisis Line or National Suicide Prevention Line, chaplains, veteran service organizations, other healthcare providers, or their boss. About 10% stated that they would not trust talking with anyone about their thoughts of suicide (Beatty et al., 2023).

6.1 Suicide Warning Signs

Though not everyone who is contemplating suicide gives indications of the extent of their distress, the National Institute of Mental Health has identified some common warning signs (NIMH, revised 2022):

Talking about:

• Wanting to die
• Great guilt or shame
• Being a burden to others

Feeling:

• Empty, hopeless, trapped, or having no reason to live
• Extremely sad, more anxious, agitated, or full of rage
• Unbearable emotional or physical pain

Changing behavior, such as:

• Making a plan or researching ways to die
• Withdrawing from friends, saying goodbye, giving away important items, or making a will
• Taking dangerous risks such as driving extremely fast
• Displaying extreme mood swings
• Eating or sleeping more or less
• Using drugs or alcohol more often

If these warning signs apply to you or someone you know, get help as soon as possible, particularly if the behavior is new or has increased recently.

Suicide is a preventable public health problem, according to the CDC (Centers for Disease Control and Prevention), which has drawn up a prevention resource, with strategies from strengthening economic supports to teaching coping and problem-solving skills. Though many factors contribute to suicide, the COVID-19 pandemic and the overdose epidemic have taken an outsized toll on mental health in America.

Even very young people are susceptible to suicide. In 2020, suicide was the second leading cause of death for people ages 10-14 and 25-34 years. Non-Hispanic American Indian or Alaska Native (AI/AN) people have the highest suicide rates, followed by non-Hispanic White people. Racism, historical trauma, and long-lasting inequities such as disproportionate exposure to poverty have contributed to higher suicide rates among non-Hispanic AI/AN youth and other groups who have been marginalized. Between 2009-2019, Black adolescents were estimated to have the highest prevalence of suicide attempts. Veterans are also disproportionately affected, as are people who live in rural areas. Transition periods are high-risk, such as the transition between military and civilian life, work into retirement, and high school to college (CDC, 2022).

6.2 Risk Factors for Suicide

Suicide is often preventable. But according to the CDC, there are many categories of risk factor, from a personal history of trauma and dysfunctional relationships to community stressors (CDC, 2022):

Individual risk factors: Previous suicide attempt, history of depression and other mental illnesses, serious illness such as chronic pain, criminal/legal problems, job/financial problems or loss, impulsive or aggressive tendencies, substance misuse, current or prior history of adverse childhood experiences, sense of hopelessness, violence victimization and/or perpetration.

Relationship risk factors: Bullying, family/loved one’s history of suicide, loss of relationships, high conflict or violent relationships, social isolation.

Community risk factors: Lack of access to healthcare, suicide cluster in the community, stress of acculturation, community violence, historical trauma, discrimination.

Societal risk factors: Stigma associated with help-seeking and mental illness, easy access to lethal means of suicide among people at risk, unsafe media portrayals of suicide.

Substance use disorders and adverse childhood experiences are associated with suicide risk, especially early use of alcohol. Losing a loved one to overdose or suicide during childhood can increase a person’s risk of overdose or suicide later in life (CDC, 2022).

6.3 Protective Factors Against Suicide

The presence of risk factors does not decree that suicide is inevitable. There are many protective factors that can promote resilience, both at the individual and community levels (CDC 2022):

Individual protective factors: Effective coping and problem-solving skills, reasons for living (for example, family, friends, pets, etc.), strong sense of cultural identity.

Relationship protective factors: Support from partners, friends, and family, feeling connected to others.

Community protective factors: Feeling connected to school, community, and other social institutions, availability of consistent and high quality physical and behavioral healthcare.

Societal protective factors: Reduced access to lethal means of suicide among people at risk, cultural, religious, or moral objections to suicide.

Stable housing initiatives have been shown to reduce suicide among veterans, such as the Health Care for Homeless Veterans and Safe Haven programs. Rapid rehousing programs for veterans and their families, such as the Supportive Services for Veteran Families, transitional housing and permanent supportive housing through the US Department of Housing and Urban Development and VA, have all reduced homelessness among veterans, removing a significant risk factor for suicide.

In terms of mental health delivery, especially in poverty-stricken rural areas, telehealth has been shown to decrease suicidal ideation.

The CDC also recommends gatekeeper training, using Applied Suicide Intervention Training Skills (ASIST) for counselors responding to calls on suicide prevention hotlines. Another training program, the Garrett Lee Smith Suicide Prevention Program, is in use in 50 states and by 50 tribes. One evaluation found that there were fewer suicide deaths among young people in the counties that were using the GLS program.

Interventions are key and should be repeated. Making a safety plan with someone who is considering suicide is also important. The suicidal person and a provider or trusted friend or family member should know what their warning signs are and how to implement a coping strategy. This could be as simple as going for a walk, listening to uplifting music, or talking to a friend or a professional counselor. Counselors are available for free, confidential consultations by dialing 988 and selecting option 1 for veterans. Interventions should be followed up with at least two structured contacts.

6.4 Screening for Suicidal Ideation

Suicide can often be prevented. Screening tools such as the Columbia Suicide Severity Risk Scale, can be used in many settings. The scale was first developed to reduce suicide among adolescents and is now used throughout the world. Over 600 peer-reviewed studies have shown its effectiveness, citing one large acute care system that saw a 50% reduction in suicides since implementing the scale (Columbia University, 2021).

The protocol is intended to be used by people who have been trained in administering it and are able to take the recommended steps if the person answering the questions shows a high risk of suicidality. It contains six questions (Columbia Lighthouse Project, 2016):

1. Have you wished you were dead or wished you could go to sleep and not wake up?
2. Have you actually had any thoughts about killing yourself?
3. Have you thought about how you might do this?
4. Have you had any intention of acting on these thoughts of killing yourself, as opposed to you having the thoughts but you definitely would not act on them?
5. Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?
6. Have you done anything, started to do anything, or prepared to do anything to end your life?

6.5 Acknowledging Grief

Grief, especially complicated grief, is a common reaction that often co-occurs with PTSD and major depressive disorder. Complicated grief can be associated with intense yearning and preoccupation with the deceased, experiences of emotional pain and numbing, feelings that life is meaningless, and difficulties engaging in social relationships and activities associated with their loss (Gros et al., 2023). It may also lead to heightened suicide risk and physical health problems like high blood pressure and heart troubles. Yearning is specific to complicated grief, though the disorder often co-occurs with depression and PTSD.

Though almost everyone will experience grief at some point in their lives, approximately 10% of bereaved people will have a prolonged grief reaction that causes significant functional impairment. A recent study of veterans seeing mental healthcare found that nearly half exhibited symptoms of complicated grief. The loss of a fallen fellow service member can reverberate for decades, at levels similar to spousal loss. This is significant, because patients who are overwhelmed by grief often do not respond as successfully to treatments for PTSD as those whose grief is less severe (Simon et al., 2020).

The loss of a loved one often comes with many painful adjustments, like being forced into single parenthood and making tough financial decisions. In addition to emotions like denial, guilt and anger, the recently bereaved may experience physical illnesses, anxiety attacks, and chronic fatigue. People grieving should be encouraged to seek the company of friends and family who care about them, support groups or pastoral care from a spiritual advisor. They should be counseled to take care of themselves by eating properly, exercising, resting, and staying away from alcohol and drugs. A mental health clinician can offer guidance as the bereaved work through their loss.

It can be especially difficult for a recently widowed parent to help a child grieve in a healthy way. Children may have outbursts, revert developmentally, or talk incessantly about death. Being able to model appropriate coping skills may be the most difficult parenting task a parent will ever have. Mental Health America offers a variety of resources (MHA, 2024):

• Tragedy Assistance Program for Survivors, Inc. assists people who have lost family members in the Armed Forces. TAPS provides a survivor-peer support network, grief counseling referrals, and crisis information and can be reached at 1-800-959-TAPS (8277) or www.taps.org.
• The Army Family Assistance Hotline is 1-800-833-6622, and the Army Reservist Hotline is 1-800-318-5298.
• The number for Marine Corps Community Service Centers West of the Mississippi is 1-800-253-1624; and, East of the Mississippi, the number is 1-800-336-4663.

You may be eligible for bereavement counseling if you’re the surviving spouse, child, or parent of someone who fits one of these descriptions (DVA, 2025, January 6):

• A service member who died while serving their country, or
• a Reservist or National Guard member who died while on active duty, or
• a Veteran who was receiving Vet Center services at the time of their death, or
• a Veteran or service member who died by suicide.

The surviving spouse, child, or parent of a service member or veteran who died may qualify for bereavement counseling. Free services include outreach, counseling and referrals, at community-based Vet Centers or other locations, or through telehealth (DVA, 2024, October 30).