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Preventing Veteran suicide was the highest clinical priority of outgoing VA Secretary Dr. David Shulkin, and that priority is likely to continue for our new Secretary. The problem of suicide is a national problem rather than one specific to VA—along with drug overdoses and alcohol-related deaths, suicide is part of an epidemic of "deaths of despair" that have contributed to rising all-cause mortality this century among white non-Hispanic Americans without a college degree.1 The problem of suicide among Veterans, however, has unique aspects that make it a distinct and compelling issue.
First, between 2001 and 2014, suicide rates were higher among Veterans compared to their civilian counterparts.2 Second, though the role of combat remains uncertain, suicide rates have increased among active-duty military,3 and clusters of suicides among isolated returning combat units have called attention to the possible contribution of combat-related trauma and PTSD. It is particularly heartbreaking when a servicemember survives the dangers of war only to take his or her own life when safely back home. Third, the risk of suicide is dramatically increased in women Veterans (2.5 fold higher than civilian women) and has risen substantially over the past two decades. Finally, whereas civilian suicide rates are highest among men over age 75, among Veterans seeking care in VA, suicide rates are now highest among men aged 18-29. These figures are not an indictment of the VA health system—suicide rates are lower among Veterans who are cared for by VHA than among those outside our system, and suicide rates within VHA have declined among those treated for specific mental health conditions. But the steadily increasing burden of PTSD, depression, and drug and alcohol use disorders among those seeking VA healthcare has caused the number of suicides to rise.
As the individual commentaries in this issue of FORUM indicate, there are many things we know about Veteran suicide but many more we don't. We know that nearly two-thirds of Veteran suicides are committed with firearms, and that high gun ownership may be part of the increased risk among Veterans; however, we don't know the best way to prevent gun-related suicides among at-risk Veterans. We can now identify patients at higher risk of suicide using a variety of clinical and demographic factors incorporated into tools such as REACH VET (see Landes Research Highlight), but we don't yet know the most effective interventions to offer them once flagged. Research shows that underlying mental health problems (especially depression and substance abuse) are major risk factors, we don't yet know the most effective medical or psychological treatments for preventing suicide. In addition, risk increases during the transition from active duty to Veteran status, but the exact reasons or best interventions for that risk are unknown. Finally, we know that studying effective interventions in suicide is challenging because it remains an infrequent event and thus requires large long-term studies. Therefore, the particular nature of suicide requires creative research-clinical partnerships.
The ongoing suicide crisis compels VA and our partners in DoD to act in the face of imperfect evidence, but research is necessary to inform our partners about what is working, what may need to be revised, and what new strategies are worth testing.
David Atkins, MD, MPH, Director, HSR&D
- Case A and Deaton A. "Mortality and Morbidity in the 21st Century." Brookings Papers on Economic Activity, Spring 2017.
- "Suicide among Veterans and Other Americans," Office of Suicide Prevention. August 3, 2016. Updated August 2017, VA Office of Mental Health and Suicide Prevention.
- Anglemyer A, Miller M, Buttrey S, and Whitaker L. "Suicide Rates and Methods in Active Duty Military Personnel, 2005 to 2011: A Cohort Study," Annals of Internal
Medicine 2016; 165(3):167-74.