Approximately 17 U.S. veterans die by suicide every day—a rate that is about 1.5 times that of nonveterans after adjusting for differences in age and sex, according to the Department of Veterans Affairs (VA) 2019 National Veteran Suicide Prevention Annual Report. Among active-duty U.S. troops, suicide rates remain about on par with that of the nonmilitary U.S. population—but both are on the rise. In August, the Department of Defense (DOD) announced that 325 active duty soldiers, sailors, airmen and Marines died by suicide in 2018—40 more than in 2017 and the highest number since the department began collecting suicide data in 2001. “Nobody really knows why suicide rates continue to climb,” says Craig Bryan, PsyD, ABPP, executive director of the National Center for Veterans Studies at the University of Utah.
Many blame demographics—85% of the military is male, and men die by suicide more often than women. “But we also know that even female service members and veterans die by suicide at a higher rate than nonveterans and nonservice members,” Bryan says. In fact, according to 2017 data from the 2019 VA suicide prevention annual report, after adjusting for age, the suicide rate for women veterans was 2.2 times greater than the suicide rate for nonveteran women.
In addition to demographics, factors such as insomnia, depression, anxiety, sexual victimization, gun ownership and substance use disorders also appear to contribute to suicide risk among service members and veterans. Older veterans may also be coping with aging, stress or lingering effects stemming from their military service that have never been addressed, while many recently discharged veterans have trouble with their relationships or their transitions back to civilian life.
Now, psychologists across the country—both within and outside the DOD and the VA—are leading efforts to improve suicide risk assessment as well as conducting research to better understand and prevent military and veteran suicide. They’re also developing and piloting interventions, at both individual and community levels, to help respond to this deadly issue.
Expanding screening and evaluation
Last August, the VA and the DOD released a joint revised Clinical Practice Guideline for the Assessment and Management of Patients at Risk for Suicide. The guideline, based on the best available evidence, was developed by a multidisciplinary work group that included primary-care physicians, psychiatrists, pharmacists, nurse practitioners, nurses and social workers, as well as psychologists.
One of its evidence-based recommendations is to integrate screening for suicide risk into all clinical settings—something the VA’s Office of Mental Health and Suicide Prevention is already working to do.
The VA began universal screening for suicide risk in all primary-care settings in October 2018, and since then more than 3.8 million veterans have been screened for suicide. “It’s become one of the largest implementations of a standardized screening and evaluation process in a health-care system,” says Lisa Brenner, PhD, ABPP, a rehabilitation psychologist and director of the VA Rocky Mountain Mental Illness Research Education and Clinical Center, who has been involved in the universal screening process.
The screening and evaluation protocol has three parts: First, a primary screening for suicide risk using the Patient Health Questionnaire-9 is typically conducted by a registered nurse in the primary-care setting. If that screening is positive, the nurse will provide a warm handoff to the primary-care provider or to a licensed independent practitioner to conduct a secondary screening using the Columbia-Suicide Severity Rating Scale. If the secondary screening is positive, the primary-care provider can conduct a comprehensive suicide risk evaluation or may facilitate a handoff to other mental health staff working in the primary-care clinic to conduct the evaluation.
Another novel strategy deployed by the VA to identify those at risk is REACH VET, a computer-based statistical risk program that flags veterans based on their electronic health records. The aim of the program is to allow for preemptive care and support for veterans, in some cases before an individual even has suicidal thoughts. Once a veteran is identified by REACH VET, the veteran’s VA mental health specialist or primary-care clinician calls to check up on him or her and conduct an additional evaluation to determine if enhanced care is needed. REACH VET was implemented at all VA facilities nationally in 2017, and early results suggest it’s having a positive impact on veterans. Program evaluators have seen more health and mental health-care appointments made, a decline in missed appointments, fewer inpatient mental health admissions and lower all-cause mortality, Brenner says.
Promising interventions
After those at risk for suicide are identified, the next step is offering efficacious interventions. Over the past 10 years, researchers have found that cognitive behavioral therapy (CBT) and other evidence-based interventions can reduce suicidal thoughts and behavior among at-risk veterans (Archives of Suicide Research, Vol. 20, No. 4, 2016). But a limitation to these psychotherapy approaches is that they require multiple sessions and cannot be easily implemented in acute care settings, says psychologist Gregory Brown, PhD, director of the Center for the Prevention of Suicide, a professor of psychiatry at the University of Pennsylvania, and the lead author of one such study.
“Emergency departments, for example, frequently function as the primary or sole point of contact with the health-care system for suicidal individuals—and this contact often occurs either immediately following a suicide attempt or when suicidal thoughts escalate and the individual feels in danger of acting on these thoughts,” Brown notes.
In an effort to get more immediate care to these patients, Brown and Barbara Stanley, PhD, a medical psychology professor at Columbia University, codeveloped a 20- to 40-minute intervention called the Safety Planning Intervention, designed to provide patients with coping strategies, reduce their access to potential suicide methods such as firearms and lethal medications, and help them establish follow-up treatment. A study piloting the protocol at nine VA hospital emergency departments found that patients who received this intervention were 45% less likely to attempt suicide in the six months after being discharged with a safety plan than were veterans who were simply referred for follow-up care (JAMA Psychiatry, Vol. 75, No. 9, 2018). Since this pilot study, the VA has been adopting and deploying the program in VA hospital emergency rooms nationwide.
Other promising VA and DOD suicide prevention interventions focus on technology to help patients at risk for suicide. A smartphone app developed by psychologists at DHA Connected Health (formerly the National Center for Telehealth & Technology), a branch of the Defense Health Agency, has shown preliminary success in increasing veterans’ ability to cope with unpleasant thoughts and emotions. The Virtual Hope Box app is modeled on a CBT technique that uses a physical box containing things that remind patients of positive experiences, reasons for living, people who care about them or coping resources. In the app, users can upload personally meaningful photos, videos, songs and quotes; complete puzzles, relaxation exercises and guided meditations; and access coping tools, including self-created cards and a phone contact list (Psychiatric Services, Vol. 68, No. 4, 2017).
“One of the most important aspects of suicide prevention among service members and veterans is ensuring ongoing access to mental health care for service members—particularly during times of transition, when suicide risk can be higher, says Navy Captain Carrie Kennedy, PhD, division chief of the Psychological Health Center of Excellence. Kennedy says one way the military is working to make sure service members have ongoing access to quality mental health care is through its inTransition program, which offers specialized coaching and assistance in finding a new mental health provider for active-duty service members, National Guard members, reservists and veterans. The program was created to ensure a warm handoff between mental health providers when military members are relocating to another assignment, returning from deployment, transitioning from active duty to reserve duty or vice versa, and preparing to leave military service.
“During the first several months after an individual separates from the military, there is an increased risk to psychological health,” says Kennedy, who is also the Navy’s clinical psychology specialty leader. That’s why inTransition targets service members receiving psychological care in the 12 months prior to their military transition—to help them set up care with a VA or other civilian mental health provider when they’re home. All service members and veterans are eligible for the program, and inTransition will find any service member or veteran local care, even in the absence of VA eligibility or ability to pay, Kennedy says. While the program is just beginning to measure outcomes, Kennedy says that findings show an increase in recent veterans successfully transitioning to new mental health care providers.
Focusing on lethal means safely
While much of the VA’s and the DOD’s efforts around preventing suicide focus on identifying and treating mental health issues, some suicide experts also point to the availability of lethal means, such as firearms, as an important piece of the puzzle. Research shows that approximately 70% of military suicides involve firearms, compared with around 50% of suicides in the U.S. general population.
“What we know about the military that’s unique is that they’re more likely to own firearms and know how to use them, and that they’re more likely to use firearms for the purpose of suicidal behavior as compared with the general population,” Bryan says.
In one study, for example, he and his colleagues examined the firearm storage practices of more than 1,600 active duty military personnel between 2015 and 2018 at military primary-care clinics across the United States. They found that nearly 36% of participants reported having a firearm in or around their homes, but less than a third of those with firearms said their weapons were safely stored, and nearly half indicated their firearms were either loaded and unlocked or not safely stored. Bryan says more effort is needed to encourage members of the military and veterans to safely store their firearms, and findings from nonmilitary populations suggest this is one way to reduce suicide risk.
“Locking up a gun won’t prevent an argument with a spouse or intense overwhelming stress, but it could reduce the likelihood of that circumstance resulting in a death,” Bryan says.
To that end, Bryan and his team, as well as individuals within the Veterans Health Administration, are working to educate clinicians who work with service members and veterans about the importance of asking about firearms in the home and whether they are safely stored—and educating patients about having a friend restrict their access to those firearms during stressful times.
Using communities as support
Other psychologists are looking to prevent military suicides by getting outside of military-based clinics. According to the 2019 National Veteran Suicide Prevention Annual Report, from 2016 to 2017, the suicide rate of veterans receiving recent VA care increased by 1.3%, whereas the suicide rate among veterans who were not receiving recent VA care increased by 11.8%, after adjusting for population differences by age and sex.
“Only about a third of U.S. veterans come to the VA for health care, so we need to ensure that prevention is going beyond the VA health-care setting,” says Gloria Workman, PhD, ABPP, director of research and evaluation suicide prevention with the VA’s Office of Mental Health and Suicide Prevention.
Additional state and local community engagement is one goal of a presidential task force, created in March and dubbed the President’s Roadmap to Empower Veterans and End a National Tragedy of Suicide, or PREVENTS. President Donald Trump appointed psychologist Barbara Van Dahlen, PhD, founder of the nonprofit group Give an Hour, to head the task force, which will look for ways to speed up information collection, better coordinate federal and state resources, provide increased outreach and information on available VA services, and discuss lethal means safety.
Another effort to better understand the role communities play in preventing suicide is Operation Deep Dive—a four-year research study conducted by the nonprofit America’s Warrior Partnership in collaboration with the University of Alabama and funded by the Bristol-Myers Squibb Foundation. Conducted in 14 communities across the country, the study is examining the community-based factors involved in suicide among veterans, and has developed a “sociocultural death investigation” tool to be used by researchers in conducting interviews with family members, colleagues, friends and other loved ones of deceased veterans to better understand the lives of veterans who recently died by suicide or self-harm. The goal is to identify opportunities for prevention before a veteran enters a crisis situation, says Phillip Smith, PhD, a psychology professor at the University of South Alabama who is working on the Operation Deep Dive study.
“Operation Deep Dive is really trying to understand not so much the specific mental health concerns of veterans but is looking instead at where in the community might there be prevention points where we can divert an individual who is on the trajectory to death by suicide to a different path,” he says.
