"Part of our hope is that this study will lead to more providers asking Veterans about self-injury during the patient encounter."
As the VA continues to explore new methods of suicide prevention, researchers at the Durham VA Medical Center in North Carolina believe one important indicator has gone understudied, and they are looking to change that in order to save lives.
Self-injury is woefully common among Veterans and involves behaviors ranging from intentionally burning or cutting oneself to punching walls—anything with the goal of transforming intense emotions or psychological distress into physical pain. On its own, nonsuicidal self-injury is not an action intended to end one’s life, but Dr. Tate Halverson and her team found it was often linked to a greater risk of suicidal thoughts and behavior.
Prior to 2001, Gulf War Era Veterans were more likely to die by suicide than all other age groups, according to the 2022 National Veteran Suicide Prevention report. In 2020, those rates fell for Gulf War Veterans, but rose in younger Veterans between the ages of 18 and 34. In response, VA has launched a number of initiatives to help Veterans who are at risk for suicide. A few examples are:
VA S.A.V.E. Training: A free, online suicide prevention resource to help people understand what to say (and what not to say) if a Veteran in their life is having thoughts of suicide.
Caring Letters: Focuses on mailing letters to Veterans during the year after their initial documented call to the Veterans Crisis Line. This initiative has been found to reduce the rate of suicide death, attempts and ideation.
Peer Support Outreach Call Center: Studies show Veterans who have peer mentors are more likely to keep their VA appointments and meet other important health benchmarks.
The research team first analyzed data from the Gulf War Research and Individual Testimony (GRIT) study, a national survey designed to better understand Gulf War Veterans’ health care concerns. The GRIT study was led by another Durham VA Medical Center investigator, Dr. Nathan Kimbrel. Nearly 1,200 surveys were completed and returned. The results were adjusted to account for the effects of alcohol use disorder, major depressive disorder, and posttraumatic stress disorder (PTSD). Of the Veterans who responded, nearly 8% said they had engaged in nonsuicidal self-injury in the past year, yet only half of these Veterans said they were receiving mental health services.
“The high prevalence of nonsuicidal self-injury among Veterans is alarming, because it is one of the strongest predictors of a suicide attempt identified to date, and Veterans are much more likely to die by suicide compared to non-Veterans,” Halverson said.
According to a separate study by Dr. Molly Gromatsky and colleagues, roughly 16% of Veterans engage in nonsuicidal self-injury at some point in their lifetimes, which is approximately three times higher than the rate observed in the general population. Despite being found to be a strong predictor of suicide attempts, this type of self-harm is often overlooked in men—a trend Halverson said they are seeing in VA facilities as well.
“We know that VA providers do a good job of asking patients about alcohol use, depression, PTSD, and suicide, but they are not consistently asking about nonsuicidal self-injury,” said Halverson. “Part of our hope is that this research will lead to more providers asking Veterans about nonsuicidal self-injury during the patient encounter and documenting those conversations in the medical record.”
Self-harm can be present in people with personality disorders, but it can also co-occur with conditions like posttraumatic stress disorder (PTSD) and common mood or anxiety disorders. Contrary to common belief, the rates of nonsuicidal self-injury are relatively similar between men and women, said Halverson. These types of behaviors may stem from a need to present oneself as strong, fearless, and uncomplaining—a mindset that often continues in Veterans of both genders well after their military service is over.
“One of the reasons we think we may be seeing such high rates of self-harm among Veterans is that there is a lot of guilt and shame that can occur with PTSD. There is also emotional numbing, difficulty regulating emotions, and difficulty communicating with others,” said Halverson. “Many Veterans may be trying to self-harm as a means of coping with these and other challenges.”
Halverson and her colleagues are working to find better ways to both identify self-injury tendencies in Veterans and engage with Veterans on how they prefer to be treated.
“There are a number of therapies that can treat overlapping conditions like PTSD or suicidal thoughts and behaviors. But if, for example, a Veteran is employed full-time and meeting family responsibilities, it may not make sense to refer them to intensive therapy,” she said. “That’s why we are working to develop a brief treatment for nonsuicidal self-injury that can be administered in an outpatient setting.”
Later this year, Halverson plans to launch a new study aimed at treating Veterans who engage in nonsuicidal self-injury. It will build off a treatment approach that has shown potential for decreasing self-injury in the general population by using state-of-the-art technology to make participation easier, particularly in the completion of the daily assessments that are essential for effective treatment.