The VA reports 18 veterans die by suicide per day, 1.5 times the rate of the non-veteran adult population. While we may think this rate of suicide is primarily among younger veterans, Vietnam and WWII veterans have greater odds of suicidal ideation than other veterans. There is also a common misconception that combat exposure is the primary reason that we lose so many veterans to suicide. Most veterans who die by suicide did not serve in combat. In fact, many were never even deployed to conflict zones.
Although certainly research has found that combat exposure and service in a conflict zone is a risk for suicidal ideation, several other factors have been found to contribute to veteran suicide. Importantly for providers to know, veterans outside of VA care (who are either not enrolled or haven’t received care in the past two years) represent 11 of the 18 suicides per day, a growing rate, while the number of suicides among those receiving VA care has decreased. Consequently, it is important to understand the following factors in order to avoid overlooking suicide risk in a patient who is a veteran:
SOCIAL CONNECTION AND SUICIALITY
It is not hard to imagine the sense of isolation that veterans may experience when returning to their communities, especially in light of the fact less than .5 percent of the US population serves in the military and veterans comprise 7 percent of the country’s population. Feelings of isolation or detachment from their community, poor relationships with relatives, and difficulty staying connected with military friends have been found to be risks for suicide.
Geography and access to support may also play a role in higher rates of suicide among veterans in rural areas than their non-rural counterparts. In addition, research has found that lacking a sense of purpose or meaning in life can be a risk for suicidal ideation. Thus, assessing a veteran’s level of social connectedness, detachment, and sense of purpose is important.
RELATIONSHIP STATUS AND SUICIDALITY
Among veterans who access VA healthcare services, the suicide rate is lowest among those who are married and higher among those who are divorced, have never been married, or are widowed.
CO-OCCURRING HEALTH CONDITIONS AND SUICIDALITY
Suicidal ideation among has been found to co-occur in veterans who have a range of mental, physical or behavioral health conditions including PTSD, bipolar disorder, schizophrenia, depression, anxiety, substance use disorders, sleep disorders, TBI, and chronic pain. In addition, veterans who have both PTSD and depression have a substantially higher risk of suicidal ideation.
Veterans who have received mental health treatment, inpatient mental healthcare, have previously attempted suicide, or have called a veterans crisis line also have a greater likelihood of suicide. Killing someone in combat and moral injury have been identified as suicide risks. On the other hand, veterans who have been granted military service-connected disability status may be at a lower risk for suicide.
MORAL INJURY AND SUICIALITY
As described previously, moral injury is often associated with PTSD, but it can also be a distinct risk for suicidal ideation. Dr. Shay has pointed that although PTSD captures the effects of fear, the disorder “is rarely what wrecks veterans lives or crushes them to suicide. Moral injury … does both.” Research suggests that all acts committed by others and by oneself are associated with suicidal ideation, although acts committed by oneself are associated with more severe suicidal ideation.
LETHAL MEANS AND SUICIDALITY
Veterans have been trained in use of firearms and are more likely to use a firearm in completing suicide. Women veterans in particular are far more likely to use firearms than their non-veteran counterparts. Firearms were the method of suicide in 70.7 percent of suicide deaths among veteran men and 43.2 percent of suicide deaths among women veterans in 2017. Practitioners may want to discuss access to firearms, safe storage and storing guns outside of the home when addressing suicidal ideation. The VA recommendations include assessing the level of trust in your relationship with a patient/client in deciding to talk about lethal means.
Listen to Shannon, Navy Veteran, discuss themilitary and veteran connection to firearms. (1:21)
SUICIDALITY AMONG WOMEN AND OLDER VETERANS
Although research suggests that older veterans may be more resilient than their young counterparts, too many still suffer from poor mental health, including a substantial number who have died by suicide. Two-thirds of veterans who complete suicide are age 50 or older. According to 2019 VA report, women veterans are more than 2.2 times as likely to die by suicide than non-veteran women.
Listen to Shannon, Navy Veteran, discuss agingveteran mental health and suicidality. (0:45)
VETERAN SUICIDE PREVENTION
The VA has identified a public health approach to suicide prevention that focuses on five themes:
1. Improving the process of transitioning from the military to civilian life.
2. Identifying unique needs and risks in specific veteran sub-populations.
3. Collaborating with communities to provide support that is as comprehensive as possible.
4. Educating the public about crisis intervention.
5. Expanding and improving veteran access to mental healthcare.