According to the Centers for Disease Control and Prevention, there were more than 41,000 suicides in 2013 in the United States, or 113 suicides each day. About 20 percent of those who commit suicide are Veterans.
Veterans can be at risk for suicide for a variety of reasons. Some are coping with aging, stress, or lingering effects stemming from their military service that have never been addressed. Many have underlying mental health conditions, in some cases aggravated by their military service, that increase their risk. Many recently discharged Veterans have difficulty with their relationships or their transition back to civilian life.
As part of its efforts to address this problem, VA has established a toll-free, confidential Veterans Crisis Line at 1-800-273-8255 (1-800-273-TALK). The hotline, staffed by mental health professionals 24 hours a day, seven days a week, has received more than 2 million calls (as of July 2016) since it was established in 2007. VA also offers a texting service at #838255.
Veterans and their families can chat online with trained counselors at www.VeteransCrisisLine.net. Registration with VA or enrollment in VA health care is not necessary. VA also has full-time suicide prevention coordinators at each of its 144 hospitals.
VA's Center of Excellence for Suicide Prevention, located at the Canandaigua, New York, VA Medical Center, has a mission to reduce occurrences of suicide, primarily by studying and applying public health approaches to suicide prevention.VA's Rocky Mountain Mental Illness Research, Education, and Clinical Center studies suicide with the goal of reducing suicide in the Veteran population.
Researchers at the VISN 19 Mental Illness Research, Education, and Clinical Center (MIRECC) in Denver work to provide useful information about suicide prevention in ways that are accessible to Veterans and the community at large. They also look at strategies to translate research-informed practices into everyday care.
The VISN 19 MIRECC has developed an ACE (Ask, Care, Escort) card to help Veterans, their family members, and friends learn the steps they can take to get help in order to prevent a suicide. The acronym ACE summarizes those steps.
The MIRECC's website also offers a suicide attempt survivor family resource guide, and guides to talking to children about suicide attempts in their family. Both products are available in English and Spanish.
VA is also part of the Military Suicide Research Consortium, a partnership that manages studies to increase knowledge on topics such as risk assessment, treatment, and prevention, as they pertain to suicidal behavior in the military and among Veterans.
In 2016, VA Under Secretary for Health Dr. David Shulkin announced a number of additional steps the department is taking to reduce Veteran suicide. These include:
Times of crisis can be related to chronic pain, anxiety, depression, sleeplessness, or anger, or disturbing memories of combat service. VA researchers are taking steps to protect at-risk Veterans from contemplating, attempting, and completing the act of suicide.
Investigators are exploring risk factors for suicide in Veterans and helping to improve risk assessments. They are also working to develop effective interventions and to identify crucial time periods at which to intervene.
Other researchers are developing national systems to capture and manage data relating to suicide, attempted suicide, and suicide reattempts among Veterans. These systems will help investigators determine risk and protective factors for suicidal behavior among Veterans.
Three studies of risk factors--According to a 2012 VA Evidence-based Synthesis Program report, specific risks of suicide for Veterans include posttraumatic stress disorder (PTSD), depression, anxiety, bipolar disorder, schizophrenia, substance abuse, traumatic brain injury (TBI), severe pain, and activity limitations. Demographic risk factors include being male, white, of a younger age, smoking, and having lower education levels. Other evidence suggests that since 2006, Veterans aged 18 through 29 who use VA health care are less likely to commit suicide than those who do not.
In 2014, the U.S. Army's "Study to Assess Risk and Resilience in Servicemembers" (Army STARRS), a study that analyzed data collected from more than 110,000 service members, found that increased suicide risk was associated with being a man, or a woman during deployment; white race or ethnicity; junior enlisted rank; recent demotion; and current or previous deployment. Several VA researchers are collaborators with the STARRS research team.
In 2013, another team of Department of Defense researchers, including one VA investigator, published a study that looked at risk factors associated with suicide in current and former military personnel from 2001 through 2008. Of the more than 151,000 service members and Veterans whose records were reviewed, 83 committed suicide.
The team found that factors significantly associated with an increased risk of suicide included being male, depression, manic-depressive disorder, heavy or binge drinking, and alcohol-related problems. They found that no deployment-related factors—such as combat experience, the cumulative number of days deployed, or the number of deployments—were associated with an increased risk of suicide.
The research team concluded that suicide risk in the population they studied was independently associated with male sex and mental disorders but not with military-specific variables.
Reports on suicide among Veterans—In 2013, VA released its first comprehensive report on Veterans who die by suicide. Before this report was issued, data on Veterans who died by suicide was only available for those who had sought VA health care services.
The report indicated that the percentage of Veterans who die by suicide decreased slightly from 1999 through 2009, while the estimated total number of Veterans who died by suicide increased. Investigators learned that a majority of Veteran suicides are among those aged 50 years and older, and that male Veterans who die by suicide are older than non-Veteran males who die in that way. This was not true of women, however. For women, the age distribution was similar between Veterans and non-Veterans.
Researchers found that the first four weeks after discharge from military service is a crucial time for new Veterans at risk of suicide, and that these Veterans should be intensively monitored. They also learned that the majority of Veterans who commit suicide were last seen by clinicians in an outpatient setting.
The report also profiled those who use the Veterans Crisis Line for help (mostly men between the ages of 50-59) and noted that "a high prevalence" of non-fatal suicide events result from overdoses or other intentional poisonings.
An updated report issued in 2016 represented the most comprehensive analysis to date of Veteran suicide rates. It included data from 1979 to 2014, from every state in the U.S. Among the data from that report:
Suicidal thinking among Veterans—As part of the National Health and Resilience in Veterans study, led by VA's National Center for PTSD, more than 2,000 Veterans were asked twice, in 2011 and 2013, whether they had experienced suicidal thoughts in the two weeks before the question was asked. Nearly 14 percent reported they had.
The results of the study, published in 2016, also determined that higher levels of psychiatric distress, physical health problems, and a history of substance abuse predicted chronic suicidal thinking, In addition, because many Veterans reported having had suicidal thoughts in one survey but not the other, the researchers determined thoughts of suicide can come and go over time.
This determination underscored the need for ongoing periodic monitoring of Veterans for suicidal thoughts, not just one-time screenings. Study researchers also found that being connected to others socially could keep some Veterans from thinking about suicide.
VA's Evidence-based Synthesis Program (ESP) reports on suicide prevention in Veterans—The accuracy of methods to identify those at increased risk for suicide, and the effectiveness of interventions to reduce suicide and self-directed violence, were addressed in a 2015 report by the ESP team at the VA Portland Health Care System.
The investigators looked at the effectiveness and efficacy of suicide prevention interventions in reducing suicide rates and self-directed violence. They found that in six of the eight studies they reviewed, suicide rates were lower after interventions, including studies of the Air Force Suicide Prevention Program, a program for an Army infantry division deployed to Iraq, and studies of police, college students, and health systems. Suicide rates were not lower in two studies of community programs.
They also looked at ongoing research and remaining evidence gaps in research on suicide prevention in Veterans and service members, and how these gaps could be addressed by future research. They found there are many single, inconclusive studies of various risk assessment instruments and prevention interventions; that many studies had methodological deficiencies; and that there was a lack of studies addressing possible adverse effects of suicide prevention programs.
The authors suggest that future research be directed toward more in-depth examination of promising survey questionnaires that assess suicide risk, and that additional research be done on other methods of determining who is at risk for possible suicide, including neuroimaging and biomarkers.
Suicidal thoughts and behaviors, including suicide attempts and death by suicide, are commonly found at higher rates among people with psychiatric disorders. A history of a suicide attempt is the strongest predictor of future suicide attempts and of death by suicide. VA researchers have studied these and other warning signs, in hopes of being able to prevent suicide in Veterans and others.
Non-suicidal self-injury and Veterans—A 2015 study led by researchers at the Durham VA Medical Center found that non-suicidal self-injury (purposely hurting oneself without conscious suicidal intent) is relatively common among Iraq and Afghanistan Veterans. Of the 151 Veterans of the two wars studied by the research team, 14 percent reported a history of such injuries.
Veterans with schizophrenia or bipolar disorder were excluded from the group, but there was a higher-than average proportion of Veterans with PTSD. In the study group, 35 percent had PTSD, 21 percent had depression, and 8 percent had alcohol use disorder. More than 90 percent of the group was male and 67 percent was white.
The study found that those who deliberately hurt themselves were more likely to engage in suicidal behavior. The researchers believe that these injuries could serve as a marker for identifying which Veterans are more likely to attempt suicide in the future.
Risk of suicide among Veterans with pain, TBI, and PTSD—Pain, TBI, and PTSD are known as the polytrauma clinical triad. These conditions co-occur, along with other injuries, in about 4 of 10 Veterans receiving care for polytrauma care (multiple severe injuries) in the VA system.
VA researchers from the South Texas Veterans Health Care System looked at whether the three conditions together increased the risk of suicide among Veterans above the risk of each of the conditions alone, and found they did not. They found that the riskiest combination for suicide was not pain, TBI, and PTSD; but PTSD, depression, and substance abuse.
The team's finding underscored the major role PTSD plays in the risk of suicide, and validated VA's strong focus on screening for and treating the condition.
Opioid doses and risk of suicide—Researchers with the University of Michigan and with the Serious Mental Illness Treatment, Resource and Evaluation Center and the Center for Clinical Management Research at the VA Ann Arbor Healthcare System found, in 2016, that Veterans receiving the highest doses of opioid painkillers were more than twice as likely to die by suicide, compared with those receiving the lowest doses.
The research team looked at nearly 124,000 Veterans who received VA care in 2004 and 2005. All had non-cancer chronic pain and received prescriptions for opioids. Using the National Death Index, the researchers identified 2,601 patients who died by suicide before the end of 2009.
They found that the suicide risk rose as dose increased. The researchers could not tell, however, whether there was a direct causal link between the pain medications and suicide risk. Instead, the high doses may be a marker for other factors that drive suicide, including unresolved severe chronic pain.
Algorithm identifies suicide risk—Clinicians are challenged every day to make difficult decisions regarding patients' suicide risk. In a study published in 2015, VA and National Institute of Mental Health (NIMH) researchers demonstrated that they had developed a formula that can identify very small groups of Veterans at a high risk of attempting suicide, most of whom had not been identified as a suicide risk by clinicians.
The algorithm developed by the investigators was derived by studying VA's patient population from 2001-2009. The team identified a range of factors from age, gender, and race to service-connected disabilities, homelessness, and hospitalizations that could be part of a formula for finding Veterans at high risk of suicide.
The team used the formula to identify about 600 Veterans whose suicide risk was 60 to 80 percent higher than that of other VA patients. The researchers envision the approach being used along with information obtained during clinical encounters to provide at-risk Veterans with enhanced prevention and treatment services.
Air pollution and suicide—In 2015, researchers at the VA Salt Lake City Health Care System and the University of Utah found a possible link between air pollution and suicide. The team examined the records of more than 1,500 people who died by suicide in Salt Lake County between Jan. 1, 2000, and Dec. 31, 2010. They found that the odds of completing suicide were 20 percent higher for people who had been exposed to increased levels of nitrogen dioxide in the two to three days before their deaths.
In particular, men and those between 36 to 64 years of age experienced the highest risk of suicide following short-term air pollution exposure. The research does not conclude that bad air causes suicide, but that higher levels of pollution might interact with other factors to increase suicide risk.
Killing in war and suicide risk—A 2012 study led by researchers at the San Francisco VA Medical Center and the University of California, San Francisco, found that the experience of killing in war was strongly associated with thoughts of suicide. The research team found that Veterans with more experiences involving killing were twice as likely to have reported suicidal thoughts, compared with Veterans who had fewer or no experiences.
They also found that the link between killing and actually attempting suicide was not as significant as the link between killing and suicidal thoughts.
Warning signs of suicide during health care visits—In 2013, researchers with the Center from Suicide Prevention in Canandaigua found that Veterans who commit suicide within a week of receiving health care often exhibit warning signs.
At their final health care visit, these Veterans were more than three times as likely as other Veterans to have talked about committing suicide, or to have mentioned they had thought about it. They also were more than twice as likely to have shown psychotic symptoms, such as disorganized thoughts, unfounded fears, and hallucinations.
According to the researchers, identifying these warning signs during a Veteran's heath care visit may help reduce the risk of suicide.
Biomarkers of suicide—VA researchers at the Durham VA Medical Center and the Mid-Atlantic MIRECC found, in a study published in 2014, that changes in the levels of certain amino acids in the body may contribute to suicide risk. The amino acids in question are important in regulating people's mood and behavior, although understanding their exact relationships to suicide will require further study.
Blood test for suicidality—VA researchers at the Richard L. Roudebush VA Medical Center in Indianapolis and at Indiana University have developed blood tests and questionnaires that can predict, with more than 90 percent accuracy, which mental health patients will begin thinking of suicide or attempt it.
In a study published in 2013, the researchers found that a series of ribonucleic acid (RNA) biomarkers in blood may help identify people at risk for committing suicide. (RNA is a nucleic acid that is present in all living cells that transmits genetic information.)
The biomarkers were found at significantly higher levels in the blood of both bipolar disorder patients with thoughts of suicide, and Veterans and other people who had committed suicide. All of the research subjects were men.
In 2015, the researchers published an additional study that used these biomarkers along with a recently developed questionnaire to attempt to predict thoughts of suicide in 217 male Veterans who were psychiatric patients. They found they could predict suicidal thoughts in these patients 92 percent of the time. Among patients in the group with bipolar disorder, the accuracy rate reached 98 percent.
While the studies described above and others help clinicians identify patients who are at risk of harming themselves, other VA researchers are looking into ways to decrease that risk.
RTMS and suicidal thoughts—A team of VA and Department of Defense (DoD) researchers found, in 2014, that high doses of magnetic stimulation to the part of the brain that controls emotion could effectively cut suicidal thoughts in half after only one day.
Repetitive transcranial magnetic stimulation (rTMS) involves taking an electromagnet (a wire wrapped around a solid coil), charging it with electricity, and applying it to specific points on the skull to target the underlying brain area. The result is a powerful magnetic field that can affect brain cells.
The Food and Drug Administration approved this kind of treatment for acute depression in 2008, but at lower doses than were used for this study.
The investigators looked at 41 Veterans who had been admitted to VA hospitals in a suicidal crisis—half of whom received rTMS, and the other half of whom did not. Treatment lasted for three days, and for the six-month period afterward, no one committed suicide.
While suicidal thoughts were significantly less in the group receiving the treatment after the first day, the counseling and medication the other group received had enabled them to catch up by the third day, and nine months after the beginning of treatment the two groups' levels of suicidal thoughts were identical.
Gun safety measures reduce suicide rates—Easy access to firearms may be an important risk factor for suicide among Veterans. Nearly two-thirds of all Veteran suicides involve guns. In addition, Veterans are extensively familiar with firearms, and trained to use them. Many VA patients with mental health diagnoses own firearms, and older VA primary care patients are more likely to have access to guns than are other primary care patients.
Researchers at VA's Ann Arbor Center for Clinical Management Research conducted 10 focus
groups and individual interviews with VA mental health patients, mental health clinicians, family members, VA facility leaders, and members of Veterans Service Organizations.
They found, in a study published in 2012, that several measures to promote gun safety were acceptable to both patients and providers. These included routine screening for gun access, especially for people receiving mental health care. Most study participants also agreed that clinicians should routinely speak to their patients about guns; and that there should be more education for patients, family members, and clinicians on suicide risks related to guns.
Promoting trust in Veterans with suicidal thoughts—In 2013, researchers at the VA Portland Health Care System conducted follow-up interviews with 34 Veterans who had shown evidence of suicidal thinking during risk assessments.
The study found these Veterans had often failed to disclose severe and pervasive suicidal thoughts during the screenings because they considered suicidal thoughts to be shameful and a sign of weakness. The Veterans also believed such thoughts were private and not to be discussed with strangers, worried that disclosure would lead to unwanted hospitalization or medication recommendations, and thought the computerized reminder process was perfunctory and disrespectful.
Veterans in the survey were more honest in discussing suicidal thoughts with health providers who focused on building a relationship, demonstrated genuineness and empathy, offered information on the reasons for suicide risk assessment, and used straightforward and understandable language. According to the researchers, all of these activities promoted trust, the basis for effective suicide risk screening and assessment in Veterans.
Can lithium reduce suicide attempts?—VA's Cooperative Study Program has begun a trial (CSP #590) to determine whether lithium, a mood stabilizing drug used since the 19th century, can be used to prevent suicide. The study is enrolling more than 1,800 Veterans from 28 VA medical centers who have either bipolar disorder or depression and who either recently survived a suicide attempt or were hospitalized to prevent one.
Each participant will be followed for a year, and the team will look at outcomes such as repeat suicide attempts and hospitalizations to prevent suicide as well as deaths from suicide.
Half the volunteers in the study will get a form of the drug known as lithium carbonate in an extended-release tablet to minimize side effects. The other half will get a placebo. All will get VA's standard mental health care plus extra care coordination. The study is scheduled to be completed in 2019.
Killing in combat may be independently associated with suicidal ideation. Maguen S, Metzler TJ, Bosch J, Marmar CR, Knight SJ, Neylan TC. Veterans who reported more killing experiences had twice the odds of suicidal ideation, compared to those with fewer or no killing experiences, even after adjustments for demographic variables, PTSD, depression, substance use disorders, and combat exposure. Depress Anxiety. 2012 Nov;29(11):918-23.
Feasibility and acceptability of interventions to delay gun access in VA mental health settings. Walters H, Kulkami M, Forman J, Roeder K, Travis J, Valenstein M. Several measures to delay gun access during high-risk periods for suicide were seen as acceptable and feasible if implemented thoughtfully. Gen Hosp Psychiatry. 2012 Nov-Dec;34(6):692-8.
Warning signs for suicide within a week of healthcare contact in Veteran decedents. Britten PC, Ilgen MA, Rudd MD, Conner KR. The assessment of suicidal ideation is critical to identify Veterans at immediate risk. However, recognition of psychotic symptoms may also improve identification. In addition to indicating immediate risk, some warning signs may also suggest on-going risk. Psychiatry Res. 2012 Dec 30;200(2-3):395-9.
Risk factors associated with suicide in current and former U.S. military personnel. LeardMann CA, Powell TM, Smith TC, Bell MR, Smith B, Boyko EJ, Hooper TI, Gackstetter GD, Ghamsary M, Hoge CW. In a sample of current and former military personnel observed between 2001 and 2008, suicide risk was independently associated with male sex and mental disorders but not with military-specific variables. JAMA, 2013 Aug 7:310(5):496-506.
Discovery and validation of blood biomarkers for suicidality. Le-Niculescu H, Levey DF, Ayalew M, Palmer L, Gavrin LM, Jain N, Winiger E, Bhosrekar S, Shankar G, Radel M, Bellanger E, Duckworth H, Olesek K, Vergo J, Schweitzer R, Yard M, Ballew A, Shekhar A, Sandusky GE, Schork NJ, Kurlan SM, Salomon DR, Niculescu AB 3rd. Suicidality may be underlined, at least in part, by biological mechanisms related to stress, inflammation, and apoptosis. Mol Psychiatry. 2013 Dec;18(12):1249-64.
Amino acids as biomarker candidates for suicidality in male OEF/OIF Veterans: relevance to NMDA receptor modulation and nitric oxide signaling. Szabo ST, Kitts JD, Naylor JC, Youssef NA, Strauss JL, Morey RA, Brancu M, Hamer RM, Bradford DW, VA Mid-Atlantic MIRECC Work Group, Marx CE. Profiling amino acids as possible biomarker candidates for suicidality in OEF/OIF Veterans may have clinical utility for identifying suicidal risk. Mil Med. 2014 May;179(5):486-91.
A two-site pilot randomized 3 day trial of high dose left prefrontal repetitive transcranial magnetic stimulation (rTMS) for suicidal inpatients . George MS, Raman R, Benedek DM, Pelic CG, Grammer GG, Stokes KT, Schmidt M, Spiegel C, Dealmelda N, Beaver KL, Borckart JJ, Sun X, Jain S, Stein MB. Delivering high doses of left prefrontal repetitive transcranial magnetic stimulation over three days to suicidal inpatients is possible and safe, with few side effects and no worsening of suicidal thinking. Suggestions of a rapid anti-suicide effect need to be tested for replication in a larger sample. Brain Stimul. 2014 May-Jun;7(3):421-31.
Predictors of suicide and accident death in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS): results from the Army Study to Assess Risk and Resilience in Servicemembers. Schoenbaum M, Kessler RC, Gilman SC, Colpe LJ, Heeringa SG, Stein MB, Ursano RJ, Cox KL: Army STARRS Collaborators. Predictors of Army suicides were largely similar to those reported elsewhere for civilians, although some predictors distinct to Army service emerged that deserve more in-depth analysis. JAMA Psychiatry. 2014 May;61(5):493-503.
A national cohort study of the association between the polytrauma clinical triad and suicide-related behavior among US Veterans who served in Iraq and Afghanistan. Finley EP, Bollinger M, Noel PH, Amuan ME, Copeland LA, Pubh JA, Dassori A, Palmer R, Bryan C, Pugh MJ. Although the polytrauma clinical triad was a moderate suicide-related behavior predictor, interactions among its conditions, particularly PTSD, and depression or substance abuse had larger risk increases. Am J Public Health. 2015 Feb;105(2):380-7.
Acute air pollution exposure and risk of suicide completion. Bakian AV, Huber RS, Cooh H, Gray D, Wilson P, McMahon WM, Renshaw PF. A heightened risk of suicide related to short-term exposure to airborne particulate matter was found in Salt Lake County, Utah, from 2000 to 2010. Am J Epidemiol. 2015 Mar 1; 181(5):295-303.
Non-suicidal self-injury as a predictor of active and passive suicidal ideation among Iraq/Afghanistan war Veterans. Kimbrel NA, Gratz KL, Tull MT, Morrisette SB, Meyer EC, DeBeer BB, Silvia PJ, Calhoun PC, Beckham JC. Non-suicidal self-injury may be a particularly useful marker of active suicidal ideation among Veterans. Psychiatry Res. 2015 Jun 30:227(2-3):360-2.
Predictive modeling and concentration of the risk of suicide: implications for preventive interventions in the U.S. Department of Veterans Affairs. McCarthy JF, Bossarte RM, Katz IR, Thompson C, Kemp J, Hannemann CM, Nielson C, Schoenbaum M. Predictive modeling can identify patients at high-risk of suicide who were not identified on clinical grounds. Am J Public Health, 2015 Sep;105(9):1935-42.
Understanding and predicting suicidality using a combined genomic and clinical risk assessment approach. Niculescu AB, Levey DF, Phalen PL, Le-Niculescu H, Dainton HD, Jain N, Belanger E, James A, George S, Weber H, Graham DL, Schweitzer R, Ladd TB, Learman R, Niculescu EM, Vanipenta NP, Khan FN, Mullen J, Shankar G, Cook S, Humbert C, Ballew A, Yard M, Gelbart T, Shekhar A, Schork NJ, Kurian SM, Sandusky GE, Salomon DR. The combination of a blood test and a newly developed questionnaire was able to predict suicidal ideation across psychiatric diagnoses 92 percent of the time. Mol Psychiatry. 2015 Nov;20(11):1266-85.
Opioid dose and risk of suicide. Ilgen MA, Bohnert AS, Ganoczy D, Bair MJ, McCarthy JF, Blow FC. The risk of suicide mortality was greater among individuals receiving higher doses of opioids, and treatment providers may want to view high opioid doses as a marker of an elevated risk for suicide. Pain, 2016 May;157(5):1079-84.
Nature and determinants of suicidal ideation among U.S. Veterans: results from the national health and resilience in Veterans study. Smith NB, Mota N, Tsai J, Monteith L, Harpaz-Rotem I, Southwick SM, Pietrzak RH. A significant number (13.7 percent) of Veterans have chronic, onset, or remitted suicidal ideation. J Affect Disord. 2016 Jun;197:66-73.